BUSINESS BEFORE QUESTIONS

London Local Authorities Bill [ Lords]  (By Order)

Motion made , That the Bill be now read a Second time.

Hon. Members: Object.
	 Bill to be read a Second time on Wednesday 3 February.

ORAL ANSWERS TO QUESTIONS

DUCHY OF LANCASTER

The Minister for the Cabinet Office and Chancellor of the Duchy of Lancaster was asked-

Youth Citizenship Commission

Natascha Engel: What steps her Department has taken to implement the recommendations of the Youth Citizenship Commission.

Dawn Butler: I am co-ordinating the Government response to the Youth Citizenship Commission. I have been impressed by the breadth of commitment of all Government Departments in engaging young people as active citizens in their communities and as they go through the transition to adulthood. I expect to publish my findings in response to the YCC in February, when I shall report on the significant amount of Government initiatives on delivery for young people.

Natascha Engel: I thank my hon. Friend for that answer. As she knows, the UK Youth Parliament is absolutely key to delivering on the proposals outlined by the YCC. Will she press the House authorities to provide core funding for the UK Youth Parliament to secure its future, so that it can deliver on those proposals?

Dawn Butler: I would like to congratulate my hon. Friend on all her work for the all-party parliamentary group on youth affairs. She does an excellent job. The UK Youth Parliament is a real success story: my hon. Friend will know that it held a great debate here in the House, and one of its key priorities is to lower the voting age to 16. She makes a valuable point, and I will indeed press the House authorities to try to ensure that we get some core funding for the UKYP.

David Evennett: We are all very keen to get more young people involved in the electoral process, and to ensure that they vote and participate. An election is near, so what more can the Government do to fulfil the commission's recommendation that eligible pupils should be encouraged to register via school to make sure that they participate when it comes?

Dawn Butler: The hon. Gentleman makes another valuable point. We do not need any changes in law to ensure that young people are registered in schools, colleges and universities. We need to encourage those institutions to make sure that young people are encouraged to sign on and be registered to vote when they reach 17, so that we have the maximum number participating in the next election.

Get Safe Online Campaign

Alison Seabeck: What assessment she has made of the effectiveness of her Department's Get Safe Online campaign.

Betty Williams: What steps her Department is taking to raise public awareness of internet safety.

Tessa Jowell: By sponsoring the Get Safe Online initiative, my Department continues to work with private sector partners to raise the very important issue of public awareness of internet safety. The Get Safe Online initiative has won two prestigious awards for this joint working, and it continues to increase the number and length of visits to its website. There have been more than 605,000 links to the site-far more than its US counterpart, which has achieved only 25,000.

Alison Seabeck: I thank my right hon. Friend for her reply. A lot of people in my constituency still enjoy using cheques, which is a good thing, but more and more people-especially elderly people-are seeking to shop online because it is easy. What additional support and advice can she offer older users of the internet, who may be less familiar with the systems? What protections are in place?

Tessa Jowell: My hon. Friend has been a long-standing campaigner on this issue on behalf of her elderly constituents. It is an extremely important matter, as people over 65 are the fastest growing group of internet users. That may seem slightly counter-intuitive, but that group of users grew by 15 per cent. in 2009 over the previous year, whereas the number of younger people using the internet grew by only 3 per cent. in the same period. Get Safe Online works specifically with Age Concern and has focused precisely on the important issue of security in banking and other financial transactions. It is important that the technology and content of websites always keeps ahead of fraud's capacity to cause great anxiety and distress.

Betty Williams: What are my right hon. Friend and her colleagues doing to encourage new sponsors to support this very valuable initiative?

Tessa Jowell: I thank my hon. Friend for that question. Get Safe Online is a joint initiative, involving the Government and important private sector sponsors such as HSBC and Microsoft. Indeed, the Minister for the third sector, my right hon. Friend the Member for Basildon (Angela E. Smith), recently hosted a sponsorship event as a result of which two new sponsors came on stream. It is clear that sponsors understand the initiative's potential public benefit when it is presented to them. It is a very attractive sponsorship proposition.

Mark Pritchard: The Minister mentioned fraud. With an increasing number of people being used as money mules, what are the Government doing to track down the foreign international gangs behind those schemes, and in particular to prosecute UK citizens who take their cut of the money?

Tessa Jowell: I would like to refer the hon. Gentleman's question to the Home Office, which takes the lead on this. I do not think that I referred specifically to money mules; I referred to protection for elderly people doing their banking and other financial transactions online. I hope that, as far as there is operational responsibility for this, his point about anticipating crime and future forms of fraud is taken into account in the constant review under the auspices of Get Safe Online working with the relevant organisations.

Jennifer Willott: There has been a dramatic increase in cyber crime related to online transactions, as the Minister mentioned. Treasury figures show that transactions have more than doubled in the last three years, but the amount of identify theft and fraud has nearly quadrupled in the same period. What are the Government doing to tackle this growing problem, and what assessment has been made of the Payments Council's decision to phase out cheques?

Tessa Jowell: My right hon. Friend the Minister of State is taking forward this very important work, meeting the relevant stakeholders. Once those discussions have concluded, she will want to make a statement to the House.

NHS Charities

Peter Bone: What discussions she has had with the Charity Commission and the Secretary of State for Health on proposed changes to the accounting treatment of NHS charities.

Angela Smith: I have discussed the accounting arrangements for NHS charities with the Charity Commission and with the Minister of State, Department of Health, my hon. Friend the Member for Corby (Phil Hope). The funds of an NHS charity are, and will continue to be, controlled by the charity's trustees for charitable purposes. The international financial reporting standard will have no effect on the independence of those funds. My hon. Friend the Member for Corby, however, has engaged with colleagues in the Treasury to seek to delay the implementation of that requirement for a further year.

Peter Bone: That was a slightly confusing response. Will the Minister make it quite clear whether the Government are pursuing the option of consolidating NHS charities on NHS balance sheets? Can we just have a simple yes or no?

Angela Smith: The hon. Gentleman may operate in a world in which yes or no does it for him, but most things in life are a bit more complex. However, I can give him a categorical assurance that the finances of NHS charities will remain entirely controlled by the trustees of those charities, which is appropriate. All that we are talking about, and the source of the confusion and misunderstanding, is a technical change to accounting and reporting arrangements. I can give the hon. Gentleman an absolute assurance that funds will remain controlled by the trustees, and will continue to be controlled by the trustees.

Bill Olner: My right hon. Friend will know that many communities give a great deal of support to NHS services, both in the hospice movement and in general health services. People would be dismayed if they thought that the moneys given voluntarily would be used against the NHS hospital budgets.

Angela Smith: I agree with my hon. Friend, and they will not be. This is purely a technical accounting matter, so I am sorry about those concerns, because they are unfounded. There is no intention whatsoever that anything should be done with charity funds, which should remain with those charities. It is a purely technical accounting matter, and I hope that those assurances will satisfy my hon. Friend.

Douglas Carswell: The Minister described this as a purely technical matter, but is there not a danger that NHS charities could be subject in effect to more central micro-management? Should we not seek in fact to decentralise control?

Angela Smith: I can assure the hon. Gentleman that there is no such intention. This arrangement will not centralise any funding or any control of those charitable funds at all.

Lindsay Hoyle: I welcome my right hon. Friend's statement that she is going to defer implementation for 12 months, but may I persuade her to go back and have further meetings, and support the  Sunday People campaign not to introduce the new arrangement at all, and ensure that people feel happy to give freely and openly to charities in the NHS without any issues?

Angela Smith: First of all, I do not have the power to introduce it or not. It is a matter for the Treasury, because it is a technical-

Lindsay Hoyle: You can do better than that Angela.

Angela Smith: If I can finish answering the question that my hon. Friend asked. [Hon. Members: "Oh!] I would always wish to respond to my hon. Friend in full, and I will continue to do so. I am sorry that there is misunderstanding about this, because we do not want people not to give to charities in the NHS because they think that the money will not be used appropriately. It is purely a technical matter but, as I said, the Health Minister, my hon. Friend the Member for Corby, has asked the Treasury to defer implementation for a year to provide the reassurance that is required.

Nick Hurd: The Charity Commission does not agree with the Government. It warned 18 months ago that the proposals risk undermining public confidence in the independence of NHS charities, but still the Government dither. Those accounting standards were never meant to be applied to charities. Other countries have chosen not to apply them in this way. They are being imposed because of bureaucratic diktat. The issue needs gripping by Ministers, so will the right hon. Lady pledge to work with colleagues in the Department of Health and Monitor to persuade the Treasury not just to defer a decision for another year, but to drop this whole nonsense altogether?

Angela Smith: I am not sure that there is any disagreement in the House on the principle of what the Government seek to do. NHS charities should have their funds independently administered by the trustees, which is the law. As I said, the Health Minister, who has been dealing with the matter with the Treasury, fully understands the views of the House and will ensure that they are represented at all times.

2011 Census

James Duddridge: What the percentage response rates were to the 2011 census rehearsal in October 2009.

Angela Smith: The census rehearsal, unlike the 2011 census, was voluntary and was carried out in just three areas. To date, the provisional percentage response is 38 per cent. overall and analysis of the rehearsal returns is still ongoing.

James Duddridge: The Minister, knowing Southend well, will know that I am appalled by those low figures, given that the 94 per cent. average at the last census was even lower in Southend. We felt that we undercounted by about 20,000 people, which cost us £7 million each year. Will the Minister agree to meet me and Southend council in the time before the general election to make sure that we are fully prepared for 2011?

Angela Smith: I would be happy to meet the hon. Gentleman. In fact, I would be happy to meet him after the general election as well, to discuss the matter. I understand the points that he makes, but the census rehearsal is voluntary. There was no publicity about it and it does not in any way reflect the response rate that we will get for the census, which I anticipate will be much the same as at the last census. What I can tell the hon. Gentleman, which will be helpful in terms of the points that he raises, is that additional work is ongoing by the Office for National Statistics, which undertakes the census, to ensure that the response rate is as high as possible. That is part of the reason for the rehearsal-to look at the actions that the ONS can and will take in areas that traditionally send in fewer response forms. So action is being taken to address the very points that he made. Indeed, the ONS has been meeting Southend council and others to look at increasing the response rate.

Julie Morgan: What efforts are being made to reach groups that are traditionally difficult to reach, such as ethnic groups or Gypsies and Travellers?

Angela Smith: The ONS has put additional work into that. More than £2 million will be spent to encourage organisations and individuals who have been more reluctant to respond to the census to encourage them to do so. Billions of pounds of public money is allocated in expenditure each year, and it is right that we have projections of where the population lives and what the needs of future populations will be. That applies to all populations in this country, so every effort will be made and extra resources will be put into ensuring that those people are able to respond.

Francis Maude: How can the cost of half a billion pounds, which is double the cost of the last census, be justified at this time of fiscal crisis? In 2001, 10 per cent. of the data was not even counted; it was imputed. Is this not a thoroughly wasteful and inaccurate exercise?

Angela Smith: Absolutely not. It is a very valuable and important exercise. The cost is about £482 million, but we estimate that the benefit to the economy of the work that has been done is about £700 million, so the benefits outweigh the cost. The cost is about 87p per person per year. For every person in the country to pay 87p per year for the benefit that we get from the census is good value.

Francis Maude: The census is not even accurate. Why are Ministers rushing to send millions of the 32-page census forms to the printers this March, a full 12 months before the census date? Should not a responsible Government be scaling the census back? Is not the answer a less intrusive, much cheaper census that offends the public less, increases compliance and therefore yields much more accurate information?

Angela Smith: I think the right hon. Gentleman struggles to make his point. If we look at the costs of censuses across the world, our census is better value for money and cheaper than those conducted in such countries as New Zealand, Canada, Australia and the USA. In the USA the census costs more than £2 per person per year-significantly more than in this country.  [Interruption.] Hon. Members may find that amusing, but I find value for money quite an important aspect. The Government are doing everything they can, working with the ONS, to ensure that the information is accurate. It is important that the response rate is as high as possible. We use the information to help to allocate Government priorities and Government expenditure, so I totally refute the right hon. Gentleman's comments.

Voluntary Sector (Government Funding)

Gary Streeter: What recent representations she has received on the effect on the voluntary sector of changes in levels of Government funding.

Angela Smith: I regularly meet third sector organisations to discuss various issues, including any potential changes to the levels of Government funding. Owing to the third sector's value to the community, public funding increased to £12 billion in the most recent financial year, an increase of more than £3.5 billion over seven years. The Government have further increased their support to the sector with a recession action plan, which is worth up to £42.5 million, and the £17.4 million hardship fund provided additional support. We have also funded a website that provides a one-stop shop for information about funding and financial opportunities, including advice and guidance on sustainable funding opportunities.

Gary Streeter: I am very grateful to the Minister. Whoever wins the next election, there are likely to be spending cuts in national and local government, and that will inevitably reduce the amount of funding for the third sector just at a time when its burden of social care is on the increase. How does the Minister intend to square that circle?

Angela Smith: The issue of local government funding has caused the third sector considerable concern, and we have been working with local government and those who commission services from the third sector to ensure that commissioners are aware of the value of the third sector and how they can best apply for the work that it undertakes on behalf of local government. In terms of social care, that is the most crucial consideration.

Greg Mulholland: There are issues with Government funding, but council budgets are under huge pressure, too, and, in the drive to enable the third sector to undertake core social services, that is leading to a double pincer movement for many local charities. What will the Minister do to ensure that councils do not simply say, "We cannot fund you," and that we do not lose the core social services that councils used to run?

Angela Smith: If third sector organisations are undertaking core social services, they will be doing so on behalf of the local authority, which will fund those services. I say to all local authorities, look for the third sector's value for money and its contribution to the overall objectives of the council and the overall benefits of the area. I am convinced that, when those issues are taken into account and councils see the value that the third sector brings to their area, it will impact on their funding decisions.

William McCrea: Surely the Minister accepts that the voluntary sector makes a vital contribution to the well-being of our society. Therefore, in these difficult financial times, financial support should be strengthened rather than diminished.

Angela Smith: It is gratifying to receive so much support for Government funding of the third sector; it has not always been forthcoming from the Opposition. We have addressed those funding issues. During the recession, the Government have given an extra £42.5 million to the third sector, and that support has been absolutely crucial. We want to ensure that we still support the third sector, but we will not regard it as a cheap option for the provision of public services. It is a quality option that deserves to be properly funded.

Government Information Service

Norman Baker: What the work programme of the Government Information Service is for the next 12 months; and if she will make a statement.

Dawn Butler: The Government Communication Network is the successor to the Government Information Service, which was disbanded in 1997. Over the next 12 months, the permanent secretary at the GCN will improve the professional skills of communicators throughout the civil service, maintain professional standards, increase efficiency and deliver maximum value for money. Effective communication performs a critical role in providing important information to the public and improving access to public services. The Government will continue to use communications in support of their policy agenda, building on current successful campaigns.

Norman Baker: I am grateful to the Minister, and I am sure that the Government Communication Network does a marvellous job, but at a time when we are looking to ensure that public money is well spent, will she explain why, for example, it is necessary for the Ministry of Defence to have 255 people employed in communication?

Dawn Butler: Over the years, there has been a lot of demand on press officers' time. I will give the hon. Gentleman some figures. There are 374 media personnel in the Press Gallery and more than 3,000 journalists at the BBC, and each of their queries demands a response. On average, the Department for Children, Schools and Families, for instance, receives 600 calls a day. The increase in numbers is a direct response to the increased number of questions to Departments.

Charities (Regulatory Burden)

Philip Hollobone: If she will take steps to reduce the regulatory burden on charitable organisations.

Angela Smith: The Government are committed to cutting burdens on charities and other third sector organisations. Further plans outlining how this will be achieved were published last month. The changes that we have already made to charity law and to the accounting and reporting thresholds have resulted in savings for up to 5,000 charities.

Philip Hollobone: Gift Aid is a wonderful thing, but it is complicated to administer and particularly costly for smaller charities. When can we have some sensible proposals from the right hon. Lady to simplify and reform the system?

Angela Smith: Gift Aid is a matter for the Treasury. However, I have regular meetings with representatives from the third sector, as well as with Treasury Ministers, who are reviewing the operation of Gift Aid to see what more they can do to assist charities in this regard.

Tom Levitt: Is it not the case that the Charities Act 2006 brought rationalisation to the regulations governing the charities sector and therefore made it much easier, in many ways, for them to function? Is it not also the case that where third sector organisations are delivering other services such as hospices and so on, they must be regulated in terms of the service that they are delivering? What is important, therefore, is not the quantity but the quality of the regulation that we have imposed.

Angela Smith: My hon. Friend, who has vast knowledge of the charitable sector, makes a valid point. This is a matter of balance. We need to ensure that there is adequate regulation to protect donors' money and the services that they provide, but we do not want to overburden those organisations with unnecessary regulation.

Ann Winterton: As charities are finding it extremely difficult to maintain income streams because of the fragility of the economy- [ Interruption. ]

Mr. Speaker: Order. I am sorry to interrupt the hon. Lady, but there are far too many private conversations taking place in the Chamber. That is very unfair to the hon. Lady and to the Minister answering the question.

Ann Winterton: I will start again, Mr. Speaker.
	As charities are finding it increasingly difficult to maintain income streams, would not now be the very best time to try to reduce the regulatory burden even further to minimise the adverse effects on all charities, including NHS charities?

Angela Smith: I do not think the hon. Lady heard my answer to the original question as regards exactly what we are doing. We are publishing plans outlining what more we can do. However, the measures that we have taken to date in relation to charity registration, and other matters, have been welcomed by charities, and we will continue to do what we can to support them.

Advice and Advocacy Services

Hugh Bayley: If she will take steps to ensure that third sector organisations have sufficient resources to provide advice and advocacy services for people employed by companies that do not recognise trade unions.

Angela Smith: Because of the third sector's value to the community, public funding increased to £12 billion in the last financial year, which amounts to more than £3.5 billion extra over the past seven years. During the recession, we have provided additional funding to advice centres and to the communities they help. That includes an extra £13 million for legal aid, an extra £10 million for additional hours of service by citizens advice bureaux, and more than £6 million for information, advice and guidance services and hardship funds. These services are open to those in every community irrespective of their employment status.

Hugh Bayley: The national minimum wage protects the earnings of vulnerable workers, but during the recession bad employers have sacked low-paid staff or unfairly changed their working conditions, especially in non-unionised workplaces. What have the Government done to support vulnerable workers to ensure that they get good advice and representation about their rights at work?

Angela Smith: I would urge every member of the public in employment to be a member of a trade union that protects their rights. However, the Government provide additional support to ACAS, to the pay and work rights helpline, and to the Directgov website. We also have a campaign to ensure that workers are aware of their rights at work so they cannot be discriminated against and treated as my hon. Friend describes.

Grassroots Grant Programme

Clive Efford: What recent assessment she has made of the effects on local communities of her Department's grassroots grants programme.

Angela Smith: The £130 million grassroots grants programme has already provided more than 13,000 grants to small charities and voluntary organisations, totalling more than £33 million. Those grants have enabled small groups across England to do what they think is best to meet the needs of their own communities. More than £13 million has been received in donations from businesses and individuals, which has been boosted by the Government's provision of £25 million through match funding.

Clive Efford: Does my right hon. Friend agree that voluntary organisations in receipt of that money are best placed to provide opportunities for young people to get employment through sport and training opportunities, and that that provides people with an excellent opportunity to participate in making their communities better?

Angela Smith: I would commend my hon. Friend for the work that he has done in his constituency on this issue, working with the third sector and encouraging young people to volunteer and engage. He is absolutely right that the ability to volunteer seems to be a route into employment because of the skills and confidence that people gain through volunteering.

Charities (Regulatory Burden)

Tim Loughton: If she will take steps to reduce the regulatory burden on charitable organisations.

Angela Smith: I refer the hon. Gentleman to the answer that I gave to the hon. Member for Kettering (Mr. Hollobone) a moment ago about how the Government are reducing burdens on charities and the voluntary sector.

Tim Loughton: I recently visited a mental health charity that was getting its funding from 27 different sources and having to fill in 27 audits and 27 accounts of how it was doing its job properly every year. It was having to employ at least one full-time person just to do the paperwork. Surely that is a nonsense and we can streamline that whole system.

Angela Smith: We can to an extent, and one thing that we can do is consider having one reporting system for such organisations. However, I do not think for a minute that the hon. Gentleman is suggesting that some of the independent funding organisations should not give money to such charities. I commend the charity that he has in mind for being so successful in gaining funding from every source. We are looking into the issue of reporting and forms and working with the sector on it.

PRIME MINISTER

The Prime Minister was asked-

Engagements

John Whittingdale: If he will list his official engagements for Wednesday 27 January.

Harriet Harman: I have been asked to reply.
	As the House will know, my right hon. Friend the Prime Minister is in Northern Ireland, where talks are ongoing to secure agreement on the devolution of policing and justice powers. The Prime Minister will make a written statement to update the House later and place it in the Library of both Houses.
	I am sure the whole House will wish to join me in paying tribute to Rifleman Peter Aldridge from 4th Battalion the Rifles, serving as part of 3 Rifles Battle Group, and acting Lance Corporal Daniel Cooper from 3rd Battalion the Rifles, who have died in Afghanistan. They were both heroes who displayed extraordinary courage, spirit and absolute commitment to the tasks that were before them and their colleagues, who, along with their families and friends, will remember them with great, great pride.

John Whittingdale: May I join the Leader of the House in paying tribute to those who have lost their lives in the service of their country? Is she aware that the compensation paid by the Ministry of Defence to the families of those killed in action is then taken into account when calculating benefit assessments, with the result that some families receive no compensation at all and others are actually left worse off? Will she look at that as a matter of urgency to see what can be done to put it right?

Harriet Harman: The Ministry of Defence has been very concerned indeed to ensure that we support those who have been injured in the line of service. The Secretary of State for Defence produced a Command Paper that particularly addressed the issue of support for veterans. There has been a big upgrading of the compensation scheme and a further review of the scheme is under way. The Secretary of State for Defence has been working closely with the Secretary of State for Work and Pensions on this.

Mark Todd: Our economy will rely increasingly on export-oriented manufacturing industries. Toyota, Rolls-Royce, JCB and others employ about a third of the work force in my area in high added-value manufacturing. What can the Government do to improve the performance of our exported-oriented manufacturing sector, to make it more successful in future for the benefit of us all?

Harriet Harman: We recognise the importance of manufacturing in South Derbyshire, where between them the aerospace, automotive and railway sectors in the area directly employ more than 32,000 people and account for more than £10.3 billion of economic output. My hon. Friend strongly supports manufacturing in his area, and we have an advanced manufacturing package of support for skills and a manufacturing advisory service. We look forward to strong growth ahead in this sector.

William Hague: We wish the Prime Minister well in his endeavours in Northern Ireland because we all want the devolution of policing and justice to be completed and progress in Northern Ireland to continue.
	I join the Leader of the House in paying tribute to Lance Corporal Daniel Cooper and Rifleman Peter Aldridge, who have joined the lengthening list that is read out in the House of members of the armed forces who have died serving this country.
	On that subject, we welcome the appointment of a new NATO civilian representative in Afghanistan, and the fact that it is the current British ambassador to Afghanistan, Mark Sedwill, whom we all hold in very high regard. Are the Government confident that his work will be closely co-ordinated with that of the United Nations so that, this time, military gains will be followed by effective reconstruction?

Harriet Harman: Indeed, and I thank the right hon. Gentleman for his commendation of that distinguished diplomat. It is precisely to support that work that the conference is to be held in London to look at taking forward issues on Afghanistan. There are 70 countries attending, as well as the UN Secretary-General, Ban Ki-moon.

William Hague: Looking ahead to that conference tomorrow, should we not recall the lessons of the previous Afghan conference in London in 2006, which set dozens of extremely ambitious objectives for Afghanistan, most of which have never been met? Do the Government agree that, this time, the conference should focus on realistic goals that can be delivered, concentrating on improved governance and reintegrating former Taliban members? Will the Government seek regular reviews of the progress made, including at the conference proposed for Kabul in a few months?

Harriet Harman: Of course, we are looking to ensure that we play our part so that, in Afghanistan, we have the right military action to tackle terrorism, we support Afghanisation of the armed forces and the police services, and we have economic and political development. I would have thought that the right hon. Gentleman would take the opportunity to support the work that will go on tomorrow instead of simply carping.

William Hague: The right hon. and learned Lady should know the position. Immediately after Question Time, my right hon. Friend the Leader of the Opposition and I will visit President Karzai to push forward exactly the same agenda as the Government, so there is no need to make party political points about that important subject.
	Doubtless, President Obama will mention Afghanistan in his State of the Union address tonight, but he is also expected to talk about reforms to the regulation of the banking system. No country was left more exposed to the failure of the banking system than the United Kingdom. President Obama has called for retail banks to be prevented from getting involved in large-scale proprietary trading. Why are the Government not supporting the President's proposals enthusiastically and working with him to realise them?

Harriet Harman: We are working very closely internationally, including, of course, with President Obama. The United States has different structures and different problems in its banking system, which the US Government are seeking to address. We have been addressing the problems in our banking system, and it is important that we all work together internationally to ensure that we can deal with the problems that have so affected all our economies.

William Hague: Well, of course it is important to work together internationally, but the Prime Minister said that he did not envisage a
	"divide in future between... retail and corporate deposit taking... and investment banking and trading conducted at an international level."
	That is the Prime Minister's stated position, which is very different from the President's, and I put it to the Leader of the House that the Prime Minister is probably wrong.
	Let me ask about something else for which President Obama has called. There is a clear case for a levy to compensate taxpayers for what happened in the past and what may happen in future. Is it not time to work with the President on agreeing the sort of levy that he proposes and drop the Prime Minister's Tobin tax on transactions, which has been rejected throughout the world and was ridiculed yesterday by the Governor of the Bank of England?

Harriet Harman: We have never argued for a one-size-fits-all solution, with every single country taking the same action. We have always agreed that all countries should work together-whether in the G20 or the European Union-to tackle the global economic crisis. We agree with President Obama and just about every other country in the world that we need a fiscal stimulus to support the economy in recovery. The only people who seem to disagree with that are the official Opposition.

William Hague: President Obama has just announced a freeze on spending in the United States and the UK Government have just raised the rate of VAT, which is hardly a fiscal stimulus. The Governor of the Bank of England said that President Obama's proposal is much more serious than the Prime Minister's Tobin tax. In fact, the Governor said that he could not think of anyone internationally who was enthusiastic about the Prime Minister's idea, so let me ask about a third aspect of banking reform.
	There is a growing consensus that only central banks have the authority, ability and know-how to maintain proper supervision of the banks. The Prime Minister took that power away from the Bank of England in 1997 and created a system that failed. Given that countries such as the United States and Germany want their central banks to have more responsibility for banking supervision, will the Government now change their policy and adopt that approach?

Harriet Harman: Obviously, what America has been doing is dealing with a very fragmented system of regulation, which involved no fewer than eight regulators. We have already rationalised the system of regulation. What is important is that the organisations have the right powers within the right framework, and that is what the Financial Services Bill and other measures are determined to ensure. The Conservatives said they wanted less regulation when they were in government, so it is good to hear that they are supporting firm action to tackle irresponsibility in the markets.

William Hague: It was the Prime Minister in 2007 who trumpeted his record-as he thought of it-of deregulation in the City and said we could look forward to a
	"golden age for the City"
	from then on. Is it not clear that the Prime was wrong and is wrong now on the system of financial supervision, wrong on the Tobin tax, wrong to build an economy based on debt, and wrong not to back the United States on banking reform? Are not those failures just another part of a miserable record, in which we have the biggest budget deficit in peacetime history, the largest bank bail-out in the world, the deepest recession since the 1930s and the weakest recovery in the G20? Does the right hon. and learned Lady think it is time to back some of the United States' proposals to sort out the banks in future?

Harriet Harman: We have helped the economy through the recession and supported the recovery. When the right hon. Gentleman was in government and sitting in the Cabinet, there were double the number of repossessions; when he was in government, there were three times as many bankruptcies; and when he was in government in a recession, there were four times as many job losses. I have to say that his reversing is even worse than mine. We are building up Britain, and the Conservatives are trying to talk it down.

Gisela Stuart: Could the Leader of the House have discussions with her colleagues in the Treasury and the Department for Transport to ensure that we get a decision on the high-speed rail link this side of the general election, and that, when we get that decision, Birmingham and the west midlands get the links they deserve?

Harriet Harman: We are very strongly supporting investment in our rail system, which is part of our economic infrastructure, and we will make sure that those decisions come forward to support manufacturing and the economy in Birmingham as soon as possible.

Vincent Cable: May I add my condolences for the loss of Lance Corporal Cooper and Rifleman Aldridge?
	May I congratulate the Leader of the House on her foresight in establishing the National Equality Panel, which reported today? It helpfully reminds us that after 18 years of Conservative Government, inequality had widened and reached the level described in the report as "shocking". Will she explain why now, after 12 years of Labour Government, income inequalities are the same-still shocking-wealth inequalities in shares and property are worse, and, as we discovered on Monday of this week, child poverty is growing?

Harriet Harman: I join the hon. Gentleman in thanking Professor John Hills and his panel for the important report by the National Equality Panel. The hon. Gentleman is right to say that the report states that under the Conservatives- [ Interruption. ] Under the Conservatives, inequality widened, and as a result of the effect of this Government's policies, most particularly on tax and benefit, the growing inequality has been stemmed. We have also tackled poverty, especially child poverty and pensioner poverty, but we think that inequality matters for the individual, for opportunity, for the economy and for a more peaceful society, so we are determined to do more to tackle inequality, which persists and can be handed down the generations.

Vincent Cable: Well, the Government may be determined, but the brutal truth is that economic inequality is getting worse. Part of the problem is the failure to reform the unfairness of the tax system. We all understand why Conservative Governments might wish to give top priority to rewarding the wealthy, but why have the Labour Government given overriding priority to cutting the tax rate that wealthy people pay on their capital gains to a lower rate than the tax paid by working people on their earnings, and why have they left wholly unreformed a property tax system under which ordinary families pay the same amount of tax on a modest family house as billionaires pay on their multi-million pound mansions?

Harriet Harman: The hon. Gentleman is simply wrong in what he says about the report's findings. It says that over the 13 years that we have been in government the effect of our tax policies, combined with our benefit policies, has been to narrow inequality. We have tackled poverty, in particular pensioner poverty and child poverty. One thing that would not help those on low and modest incomes would be the savage cuts proposed by the hon. Gentleman's party.

John McDonnell: The threat of the third runway at Heathrow continues to blight my community. Although a compensation scheme has been introduced that will protect the homes of some residents, many residents are excluded from it. It also does not cover people such as the local shopkeeper, the hairdresser and the publican who live above their premises and who will lose their homes and their livelihoods. Will the Leader of the House facilitate a meeting between local MPs and Ministers to discuss what compensation can be provided to those people?

Harriet Harman: I would certainly be happy to suggest that the Secretary of State for Transport meet my hon. Friend and other hon. Members to discuss these important issues.

Pete Wishart: Tens of thousands of people dead, a whole region destabilised, no mythical weapons of mass destruction and this week we learn of the dubious and questionable legality that took us into the war in Iraq. Does not the Leader of the House in her quieter moments and in her heart of hearts believe that her Government led us into this disastrous and immoral war on the back of one of the biggest deceits in political history?

Harriet Harman: These matters, which were debated and decided on in this House of Commons, are now the subject of the Chilcot inquiry. It is choosing the evidence to be brought before it and that it requires to be examined. It is independent and I suggest that we thank it for its work and await its report.

David Chaytor: Last week, Woodhey high school in my constituency was named as one of the country's top performing schools for sustained improvement in GCSE results. That follows £8 million of investment in new facilities. The other schools in Bury, North are awaiting their capital investment. What would be the effect on school standards if the Government's only policy were to cut the deficit further and faster than ever before?

Harriet Harman: I agree with my hon. Friend that education is important, not only for every individual to achieve their potential, but to ensure that we have a dynamic economy. I am delighted that Woodhey high school has seen such a big rise in its results, not only last year but in the last three years, and I join him in congratulating the school. Those results are due to the hard work and dedication of the teachers and pupils, but they are also thanks to the extra investment we have put in. We will continue to sustain and support investment in education.

David Jones: The Business Secretary once famously remarked that Labour was intensely relaxed about people getting filthy rich. Is the right hon. and learned Lady equally relaxed about how the Prime Minister's predecessor has decided to go about it?

Harriet Harman: We have asked the National Equality Panel to look at how we can ensure that we help social mobility and- [Interruption.]

Mr. Speaker: Order. I want to hear the answer.

Harriet Harman: We are determined to ensure that there is social mobility, and one of the important findings of the NEP report is that more unequal societies have less social mobility, which is why we are determined, with Government action, to continue to support policies that spread fairness and equality.

Michael Clapham: Will my right hon. and learned Friend join me in congratulating the Coalfields Regeneration Trust on rebuilding mining communities devastated and broken by the Tory closure programme? Is she aware that the renewal programme in mining communities has been carried out by creating 90,000 places in education and training and rebuilding 2,200 facilities in the communities? Will she urge-

Mr. Speaker: Order. Please get to the end of the sentence.

Michael Clapham: Will my right hon. and learned Friend urge her colleagues at the Department for Communities and Local Government to-

Mr. Speaker: Order. I think that we have got the thrust of it.

Harriet Harman: I will support my hon. Friend's urgings to my colleagues in the Department for Communities and Local Government, and I am delighted to join him in congratulating the Coalfields Regeneration Trust on its first 10 years of operation. I know that he has worked with fellow MPs in former mining constituencies to ensure significant regeneration in these areas, which face such challenges, particularly after the devastation of the Tory years.

Evan Harris: Question 6, Mr. Speaker.

Harriet Harman: rose-

Hon. Members: Come on!

Harriet Harman: It's all right. It will be worth waiting for-well, perhaps not.

Crown Accession

Evan Harris: What discussions he had at the Commonwealth Heads of Government meeting in November 2009 on the succession to the Crown of Catholics and women.

Harriet Harman: The Government are in contact with other countries of the realm where the Queen is Head of State about updating the rules of succession.

Evan Harris: The right hon. and learned Lady was right the second time.
	In March, the Lord Chancellor himself said that the sort of anti-Catholic and anti-woman provisions at the centre of our constitution have no place in a modern society, and that the Prime Minister was ready to consult Commonwealth Heads of Government. Will the right hon. and learned Lady suggest that he write to them, if he is too busy to consult, so that we can get on with this reform?

Harriet Harman: As the Prime Minister has said, people recognise the need for change, but that change can be brought about only by the Prime Minister working with the 16 other countries. The discussions are continuing. We cannot speak for those other countries, but we are sure that progress will be made.

Engagements

Anne Main: Before the Prime Minister goes to Her Majesty to ask for the Dissolution of the House, will the Government come before the House and give a statement to Equitable Life victims on when they can expect a fair and reasonable settlement?

Harriet Harman: Equitable Life policyholders lost out as a result of mismanagement that went back to the 1980s. There is concern on both sides of the House about that. The hon. Lady knows very well that there has been an ombudsman's report on the matter, that we have apologised for the regulatory failures that caused loss, and that we have set up a system to establish how there should be ex gratia payments. Sir John Chadwick has got this work under way and will be making his interim findings in the spring.

Chris Mullin: May I put it to my right hon. and learned Friend that one of the causes of the growth in inequality has been the extension of outsourcing of jobs that were previously done in-house? A class of working people has grown up that no longer qualifies for pensions, sick pay, redundancy pay and all the other things that in the 20th century we used quaintly to associate with civilisation. Is it not time that the Government started to discourage outsourcing?

Harriet Harman: The transfer of undertakings regulations were designed to give protection where work was transferred out from direct employment in the public sector to the private sector. However, the Equal Opportunities Commission has documented evidence to show that this has been a downward pressure on women's wages and their income in retirement. We are determined to ensure not only that people in public services can give a good service to the public, but that they are fairly treated in employment.

David Davies: Balal Khan was this week sentenced to just three years in an institution for a violent rape. Will the Minister refer that disgraceful sentence to the Attorney-General and also investigate the parents and community, to find out how that young man could have such a complete disregard for women's rights?

Harriet Harman: I am sure that the Attorney-General will have drawn to her attention the point that the hon. Gentleman has raised, which will give her the opportunity to consider whether she wants to refer that sentence to the courts.

Louise Ellman: Today is Holocaust memorial day, 65 years after the liberation of the Auschwitz-Birkenau death camp. Does my right hon. and learned Friend agree that although the evil of the holocaust is unique, its lessons must be applied to the racism and anti-Semitism of today, so that a better society can be enjoyed by everyone?

Harriet Harman: I support absolutely what my hon. Friend has said. We in this House regard Holocaust memorial day, which is today, as very important. There will be a debate in the House tomorrow and there is a book of remembrance that can be signed. The work of the Holocaust Educational Trust is very important indeed, but we must also bear in mind the lessons that come out of the holocaust about prejudice, discrimination and anti-Semitism, which we must fight wherever they rear their head in this country.

David Heath: It was revealed last week that a company in my constituency had been selling bomb detectors to the Iraqi Government that do not-indeed, cannot-work. If the Government knew about that, why did they wait until the BBC report last Friday to impose an export ban? If they did not know, why were Government agencies so curiously incurious about $85 million-worth of security equipment being sent from the United Kingdom to a war zone?

Harriet Harman: I will ask the Business Secretary to respond to the hon. Gentleman in detail on the important issue he has raised.

Geraldine Smith: My right hon. and learned Friend will be aware that Royal Mail and the Communication Workers Union are making good progress on modernisation and addressing the industrial relations problems that have bedevilled the industry. Can she now say when the Government will sort out the pensions deficit, which needs to be done as a matter of urgency?

Harriet Harman: Like my hon. Friend, the Government are strong supporters of the Royal Mail and want it to have a secure and prosperous future at a time of big change. We are committed to the universal service six days a week and to a post office network. We are also committed to changing the regulations to allow more ability to compete, and we obviously want to ensure that the pension liabilities are secure as well.

Brooks Newmark: Each year, 1,000 women die from cervical cancer. In Scotland, Wales and Northern Ireland young women can get screening at the age of 20, yet in 2004 the Government sought to increase the age for women in England to get screening to 25. Why do the Government discriminate in that way, and will they consider redressing that injustice?

Harriet Harman: We are very concerned indeed to make sure that we prevent, and have early detection for, as many cancers as possible. In that, we ensure that the necessary resources are available but we are guided in the application of those resources by clinical judgments. The hon. Gentleman is no more a scientist than I am; what we have to do is take the best advice and act on it, and make sure that there are the resources to back it. That is why we have trebled investment in the national health service.

Brian Iddon: We are desperately short of teachers in the STEM subjects-science, technology, engineering and maths-and the situation is likely to get worse as we move again to teaching the sciences separately. What impact does my right hon. and learned Friend expect if we are to recruit only first-class or upper second-class students to teach those subjects?

Harriet Harman: I urge my hon. Friend not to worry about that at all, because like so many other Tory policies it will probably be changed by this afternoon. What will be unchanged is our commitment to science, in which my hon. Friend has played a leading role.

Anti-Slavery Day

Anthony Steen: If he will make it his policy to support the establishment of an Anti-Slavery Day in the UK to raise awareness of human trafficking.

Harriet Harman: The Government are determined to combat human trafficking. We are considering the hon. Gentleman's proposal for the establishment of an awareness day, and will respond to him in due course.

Anthony Steen: We need that day even more now. Before the earthquake in Haiti, many of the 200 orphanages there were actually fronts for child trafficking. Since the earthquake, we have a new problem: 380,000 children at risk. Will the right hon. and learned Lady speak to her international aid contacts this afternoon and establish a network for children at risk, so that they have somewhere safe to be until they can trace their family or until there is time to set up some kind of arrangement to ensure their safety? The traffickers are circling. We need to make sure they do not catch the children.

Harriet Harman: I pay tribute to the hon. Gentleman for his work on the issue, which he has consistently and intelligently raised in the House. I agree that there is work to be done by the police and prosecutors internationally. There is also the work of voluntary organisations, which I know he supports, helping to bring the message warning people of the dangers of trafficking, and protecting those victims. I congratulate him on his suggestion. We will look into it.

Point of Order

Greg Hands: On a point of order, Mr. Speaker. I have given prior notification to the Member concerned.
	In Communities and Local Government questions yesterday, the hon. Member for Sheffield, Attercliffe (Mr. Betts) put a question with a wholly erroneous set of comments attributed to the leader of my council, Hammersmith and Fulham, including the statement that
	"one problem with social housing was that it was hard to get rid of these people".-[ Official Report, 26 January 2010; Vol. 504, c. 669.]
	That comment is entirely false. The leader of the council never said any such thing, so I should be grateful for your guidance, Mr. Speaker, on how we might set the record straight for what is, after all, one of Britain's best-loved and best-run local authorities.

Mr. Speaker: I thank the hon. Gentleman for his attempted point of order, but as he will know, on the strength of his experience in the House, it was not a point of order but a most interesting point of debate, which has now been placed fairly and squarely upon the record.

BILL PRESENTED
	 — 
	School Admissions Bill

Presentation and First Reading (Standing Order No. 57)
	Mr. Paul Burstow, supported by Tom Brake, presented a Bill to enable admission authorities to have regard for local authority boundaries and other defined localities when allocating school places; to provide for the appointment of an independent lay majority on local school admission forums; and for connected purposes.
	 Bill read the First time; to be read a Second time on Friday 12 March, and to be printed (Bill 57).

Young People Leaving Care (Accommodation)

Motion for leave to bring in a Bill (Standing Order No. 23)

Helen Southworth: I beg to move,
	That leave be given to bring in a Bill to make provision for minimum standards in respect of accommodation for young people leaving care; to impose a duty on local authorities to ensure that such standards are met; and for connected purposes.
	This Government have made considerable progress in the support of vulnerable children and put in place exemplary legislation and regulation to improve the outcomes for those children. The Children and Young Persons Act 2008 established laudable principles and objectives to improve the experience of young people in care, to deliver high-quality corporate parenting, to listen and respond to young people, to bring stability and continuity into every aspect of a child's care, and to create an uncompromising culture of high aspirations.
	Those are incredibly laudable objectives, but they need to be underpinned by detail. Indeed, the Act is largely underpinned by extensive regulation, one aspect of which is currently out for consultation. It relates to young people between the ages of 16 and 18 who are in the care of a local authority and who are being placed in accommodation in an unregulated setting-that is, not in a children's home or a foster home. This is the first time that there will have been a definition of suitable accommodation for those young people.
	I shall refer to those plans in detail in a moment, in the context of my Bill, which would put in place minimum standards for young people of 18-plus who are leaving the care of a local authority and making the transition to independent living. As we all know, that time of a young person's life involves an awful lot of support needs. They depend on other people to help out when they are trying to take those first steps. They are trying to work out whether a particular course of action is the sensible one, and whether it will take them where they want to go. They are asking themselves, "Where do I want to go?" or, in some cases, "Who do I want to be?" and "How can I take the steps to achieve that?"
	At the moment, there is a gap between the laudable aspirations that I have mentioned and the direct experience of people in care and leaving care, and it is our responsibility to sort that out. A young person should not have to try to second-guess the system when they have no experience of these things. They need to be supported in the same way that they would expect to be supported by a caring parent. Such a parent would ask, "Is this accommodation suitable? Is it where you want to be? Where do you want to be? Where do you want to go to school and university? Where do you want to go to college? What do you want to achieve? Have you got a job? How can we support you?" We need to be able to work effectively to provide somewhere safe and secure in which a young person can fulfil their aspirations and do as well as they possibly can. We are not in that situation at the moment.
	I have an example of a young woman who got in touch with the Who Cares Trust. She started a job in London, her first job. The work was hard and involved a lot of hours, and she had a lot of things to take into account. She needed a lot of help from her foster carers, even though she was at an age when they did not have to provide it. The flat that she had been offered was dirty. She said, "Don't tell me people live in this filth." Her foster carers could not believe it when they went in. It took a whole set of them a week to clean the place up. She said that there was grime, dust and growth on the walls, that the walls had holes in them, that plaster was missing and wallpaper was peeling off, and that there was damp and mould everywhere. She could not believe that she was expected to live in such a place, but it was the only option offered to her.
	I recently had a meeting with a group of young people who came to Parliament to tell me about their experiences, along with a group of social workers. The social workers were great people; they were helpful and supportive. They said, however, that young people up to the age of 21 were being supported. One of the girls then asked a question, and it is a question that we need to find an answer to. She asked why, if young people were being supported up to the age of 21, she had been placed in a bed and breakfast with her baby when she was 18.
	We talk about the intergenerational problems experienced by vulnerable young people, but we have the ability to help them to break out of them. We must mind the gap. At the moment, young people are telling us that they can be placed in bail hostels alongside people who have problems with drug addiction, or in places where prostitution is actively taking place. These are places where they would never have been allowed to go when they were in the care of a local authority, yet they are being placed in them by the authorities because there are no effective minimum standards.
	Some authorities are brilliant-they have worked it out and know how to do it. Some agencies are incredibly effective: the National Care Advisory Service, which works directly with local authorities and young people, has tremendous experience of what works and what can be done well. Crucially, it has involved a considerable number of young people with experience of care in drawing up what they believe should be the minimum standards for accommodation. I have been in several meetings with them and gone through these matters in detail. What I have noticed most is the close correlation between what good local authorities and children with experience of care say is the minimum standard needed, and minimum student accommodation standards drawn up by universities and colleges in consultation with their students. It defies logic that an 18-year-old at a university or college now benefits from extensive, detailed minimum standards on whether accommodation is suitable, but an 18-year-old leaving care does not.
	What is provided for an 18-year-old leaving care and going to university or college? During their time at university they have minimum standards, but during the holidays they have nothing. The basic need for standards of the most vulnerable children who go to university or college is unmet. Why must there be standards? If there are standards, the expectation is set. The Bill would define not good practice but what is safe or legal for anybody else. For a house in multiple occupation, a set of legal standards is required. Those standards must be available to our most vulnerable children.
	Significantly, I do not have the considerable time necessary to go through the recommendations of the National Care Advisory Service in detail, but young people currently have to make a decision on the hoof, on one choice. Everyone in the House knows that there is a difference between an unfair tenancy agreement and a fair one. There is a difference in terms of safety between somewhere with a lock on the door to which the person concerned has the key, and somewhere that does not. Who would feel comfortable going to sleep in a place where they did not have a lock on the door? Who would feel comfortable going to sleep in a bail hostel without a lock on the door? I have had horrifying discussions with young people about their experiences in bail hostels where they cannot lock the door. That is not good enough, it is not acceptable, it is our responsibility to do something about it, and we have the opportunity to do so.
	Currently, regulations are being put together for young people aged 16 to 18. As far as they go they are good, but they do not specify that a young person should have a private room, or that they should be able to secure it. That is not good enough, but it is significantly better than the provision for young people aged over 18. To mind the gap for young people leaving care from the age of 18, we should bring in legislation that is sufficiently robust for them to be able to challenge a poor decision, and to prevent predators moving into the market and exploiting the vulnerability of such young people. Beyond that, it must also be sufficiently robust to ensure that they are secure, safe, able to achieve, and able to grow into who they want to be and should be.
	 Question put and agreed to.
	 Ordered,
	That Helen Southworth, Derek Twigg, David Cairns, Ms Karen Buck, Ann Coffey, Mr. Kevin Barron, Mrs. Janet Dean, Christine Russell, Mike Hall, Mr. Russell Brown and Annette Brooke present the Bill.
	Helen Southworth accordingly presented the Bill.
	 Bill read the First time; to be read a Second time on Friday 12 March, and to be printed (Bill 56).

Opposition Day
	 — 
	[3rd Allotted Day]

Dementia Services

Mr. Speaker: I inform the House that I have selected the amendment in the name of the Prime Minister.

Stephen O'Brien: I beg to move,
	That this House wishes to see the quality of life improve for the 700,000 people in the UK with dementia; pays tribute to their families and carers and all those who campaign and fundraise for dementia charities; is concerned about the findings published in the National Audit Office report on Improving dementia services in England, HC 82, that showed the Government had failed to implement robustly the Dementia Strategy; calls on the Government to publish the report of the Nutrition Action Plan Delivery Board, which was submitted in July 2009, and in particular to respond to the inappropriate tube feeding of those in dementia care; deplores the inappropriate use of anti-psychotic drugs in the care of those with dementia; is concerned that 50,000 elderly people are forced to sell their home every year to pay for their long-term care; is concerned that the effect of the Personal Care at Home Bill will not help those with dementia in residential care; calls on the Government to prioritise research to combat dementia; proposes that the National Institute for Health and Clinical Excellence assess the wider societal value of treatments in its appraisals; and further calls on the Government to adopt a social care insurance model for residential care costs and to recognise dementia within a wider reform of social care.
	We have brought this motion before the House because we are deeply anxious about the welfare of the rising number of dementia sufferers and their families, and of every elderly person in the UK who is having to live with the effects of an unreformed social care sector. Let us be clear about the scale of this issue. Of the 8.2 million people who are over 65 and of the 6 million people who use social care, 700,000 people have been diagnosed with dementia in the United Kingdom-and that figure is set to double over the next 30 years. In other words, about one in 10 of all social care users has dementia. In the context of a rapidly increasing awareness generally, the Government have promised much but delivered little to this group of people.

Jeremy Wright: Does my hon. Friend agree that those figures may not tell the whole story on dementia? He has described the number of people who have been diagnosed with dementia but, as we know, many cases have not yet been diagnosed.

Stephen O'Brien: I am most grateful to my hon. Friend. He is absolutely right to have spotted that I said that 700,000 was the number of people who have been diagnosed with dementia. I did so precisely because of the under-diagnosis that occurs and the cases that will doubtless shortly be diagnosed.

Nick Palmer: On that point, the Parliamentary Office of Science and Technology says that 700,000 is the current estimate but that in fact only one in three of those people have had a formal diagnosis from a doctor, so the previous intervention was not correct.

Stephen O'Brien: The hon. Gentleman attempts to be more precise, but he will find that 700,000 is the figure for the number of people whose diagnosis has been accepted by all the agencies that need to make calculations and predictions, not least the Government. Some of that diagnosis may not have been done through a formal medical diagnosis, but it has become accepted through the other agencies as the appropriate diagnosis.

Hugo Swire: Is not this issue of diagnosis the precise point, because one of the things we were promised in the national dementia strategy was better training for general practitioners and earlier diagnosis, and that has not happened? That is why so many people are still not being properly diagnosed.

Stephen O'Brien: I am grateful to my hon. Friend for making that excellent point. He is right and he anticipates one of the issues that I hope to develop a little later in my speech.
	There are specific measures that could improve the outlook for people with dementia, and for their families and carers, but it is important to bear in mind the fact that these social care reform issues affect all our fellow citizens who need to access and use social care services. Sufferers of advanced dementia represent some of the most vulnerable older people in our society. As we consider the challenge of meeting their needs, we must pay careful attention to the wider social care reforms that could protect the health and well-being of all elderly people. I hope that we can keep that bigger picture in mind as we debate this matter today.
	First, let us consider dementia specifically. There is no masking the truth that dementia is a frightening and debilitating disease that plays havoc with the lives of those who come into contact with it, be they the sufferers of the illness, the families or the carers. The trauma of a diagnosis and the difficulty of coming to terms with the gradual loss of memory is only intensified when patients discover that little co-ordinated support is available for sufferers.
	I pay tribute to all those in the third sector-in particular the Alzheimer's Society and the Alzheimer's Research Trust-who have supported sufferers and championed their cause. I also pay tribute to the work of my hon. Friend the Member for Rugby and Kenilworth (Jeremy Wright) and the all-party group that he founded and chairs, which has been so influential. We should also pay tribute to hard-working elected members of councils across the country and their officials who are working to provide this care at a local level, as well as to all those operating in the local government departments.
	I cannot give enough praise to the family members, neighbours and friends who, as informal carers, love and care for vulnerable and elderly people and for those with dementia, who face even greater challenges. We should keep them uppermost in our deliberations and not forget the real human lives that these policy debates represent.
	Two weeks ago, the National Audit Office published a broadly critical report on the Government's dementia strategy. Among its many misgivings, it noted that
	"there has not yet been a robust approach to implementation"
	of the strategy; that
	"it has not been given the levers or urgency normally expected for such a priority";
	and that it is clear
	"that value for money will remain poor unless these weaknesses are addressed urgently."

Edward Leigh: The National Audit Office reported, of course, to the Public Accounts Committee. We had a very good hearing on this subject in October 2007. I was promised 10 times by Sir David Nicholson, the head of the NHS, that the matter would be a national priority. That commitment was given 10 times. There have been three framework directives since then and it is still not a national priority-it is only a strategy. If my hon. Friend is fortunate enough to become a Minister for Health in May, will he consider making it a national priority?

Stephen O'Brien: I am grateful to the Chairman of the PAC for that intervention and for the work that he has overseen, as well as to the NAO, which has done that work. In answer to his specific question, I am glad to confirm that we have already said that, should that happy occurrence take place, this matter will be a priority. Part of my argument will be to ask how much, if one is going to state-as the Government have-that this is a priority, that needs to be followed through with actions rather than words, including operating frameworks.

Andy Burnham: Let us be absolutely clear. Is the hon. Gentleman saying that he would make it a national target or that he would leave it to local discretion? He cannot stand there, make suggestions and posture on this issue without being absolutely clear on that point.

Stephen O'Brien: I hope that the Secretary of State will reflect on the fact that he did not use the word "priority", which was the word that I used. For some reason, he felt compelled to use the word "target", which is always a potential distortion. That was a distortion. My answer is that the issue, as I am about to make clear, concerns how the actions flow from the word "priority", once we have called it that.

David Blunkett: I must say to the hon. Gentleman that, as vice-president of the Alzheimer's Society, patron of my city's Alzheimer's group and someone who is contributing to the Alzheimer's Research Trust, I am surprised that he is making this a party political issue. Let me ask him a simple question. The thrust of the Audit Commission's review was that the strategy was good and that the new appointment of the director in charge of this matter will help, but that the £150 million allocated had not reached the parts for which it was intended because of the nature of decentralisation and the lack of ring-fencing. Given the Conservative party's commitment to the new NHS board and to even more decentralisation to professionals from the Secretary of State or politicians in this House, how could the hon. Gentleman possibly determine what a priority would be locally when he could not even determine it nationally?

Stephen O'Brien: I am grateful to the right hon. Gentleman-no doubt he will seek to catch Mr. Speaker's eye later, as that was a speech. Let me return to the intervention that he made at the beginning of it. He clearly needs to recognise that if anybody was making a party political point it was the Secretary of State, who intervened in the most tribal manner, as is fairly typical. The answers to the right hon. Gentleman's questions will, happily, become clear from what I am about to say.
	The NAO's report came on the back of a disappointingly vague Green Paper on social care and a personal care pledge by the Prime Minister that the Labour party's own Lord Lipsey has described as a "gimmick".
	Let me correct the claim in the Government's amendment that
	"the Personal Care at Home Bill will help some 400,000 people".
	It is offering free care to only 270,000 people, of whom 160,000 already receive it free. It will take only 2,384 people out of care homes-the stated aim of the policy on the human rights grounds that are critical for its intra vires-from a population of more than 500,000. It will help less than 3 per cent. of social care users. In other words, the Government have not grasped the nettle: we have an ageing population on our hands, cases of dementia are on the rise and time is running out.
	By contrast, the Opposition have led the way in recognising that if a Government are to be serious about addressing the needs of dementia sufferers and older people across the country, reforming older people's care services across health and social care in a way that is both socially and fiscally responsible must be a priority. That was precisely the answer that I gave. To cover one of the points mentioned in the intervention by the right hon. Member for Sheffield, Brightside (Mr. Blunkett), which was rapidly developing into a speech, our policies on Alzheimer's research and pooled personal budgets, our proposals to reform the National Institute for Health and Clinical Excellence's drug assessments, our home protection scheme for affordable guaranteed residential care and our commitment to a reinvigorated public health agenda have forced the Government to pick up the pace of reform.

John Mann: The hon. Gentleman mentioned fiscal responsibility and other matters. Has he had a chance to consider the approach taken by Conservative Nottinghamshire county council? Is he learning from it? The council is privatising dementia care homes, which will mean automatically that the day care service provided for dementia sufferers, which it is also cutting, will be removed in its entirety. What would he say to that county council, which has a budget meeting coming up in a few weeks' time?

Stephen O'Brien: The hon. Gentleman will no doubt have to answer to his right hon. Friend the Member for Sheffield, Brightside for introducing a party political element in his intervention. Clearly, what matters is that we should recognise that local services reflect the national priorities that have been set. If a national priority is for a dementia strategy delivered through actions on the ground rather than words, no doubt that would be more persuasive to a local council as it reached its decisions.
	The National Audit Office raised four main criticisms of the dementia strategy. First, will the Secretary of State make clear just how much of the £60 million of dementia strategy funding for 2010-11 will be spent on additional dementia services? Does he have any plans to undertake a baseline assessment to see from what starting point those services are being run? We need only look at the recent carers strategy to see how urgently this assessment is needed. It emerged before Christmas that the £50 million disbursed for emergency respite care this year never reached the front line; instead it got soaked up in local primary care trust bureaucracy. Not only does that leave dementia sufferers with little hope of benefiting from resources, but it seems particularly disingenuous for the Government to take the plaudits for pledging taxpayers' money without the funds ever reaching the front line.
	On the second criticism, will the Secretary of State tell the House what the source of funding is for meeting the £1.9 billion cost of implementing the strategy over its 10-year lifespan? To date, the Government's impact assessment has identified only £533 million of efficiency savings over 10 years, which leaves nearly three quarters-

John Mann: Will the hon. Gentleman give way?

Stephen O'Brien: I shall make progress, I think, as I have already answered the hon. Gentleman.
	To date, the Government's impact assessment has identified only £533 million of efficiency savings over 10 years, which leaves nearly three quarters of the budget unaccounted for. Does the Secretary of State agree that those diagnosed with dementia today need to know that there is a safety net of funding for their care and treatment as they face the years ahead?
	Thirdly, the Government have yet to tackle the gaping hole in the skill set of all professionals who encounter dementia patients as part of their job. The £1.9 billion dementia strategy budget covers diagnosis and early intervention in people's homes, but the NAO report points out that no estimate has been given for the cost of the pledges that the strategy makes for the training of NHS and social care staff.
	Fourthly, can the Minister explain why dementia was not included in the Department of Health's fixed national and local spending priorities-Vital Signs-in 2007? That serious omission-

Andy Burnham: Will the hon. Gentleman give way again?

Stephen O'Brien: Perhaps I can make sure that the Secretary of State knows the point that he has to answer: why was dementia not included in the Department's fixed national and local spending priorities, Vital Signs, in 2007? The vital point is that that serious omission took place only a month after the Department had asserted in a statement to the PAC that dementia was a national priority. Is dementia really a priority?

Andy Burnham: The hon. Gentleman says that he believes in local decision making in the NHS. Is he saying, at the Dispatch Box today, that he would make dementia a mandatory national requirement in tier 1 of Vital Signs? Yes or no?

Stephen O'Brien: The answer to that is, of course, no. That is because Vital Signs is the Secretary of State's target system, and it has been discredited for distorting health provision. The precise point of this debate is that the Government are not delivering the results on the ground, even when they come out with something called a dementia strategy.

Robert Key: rose-

Hugo Swire: rose-

Stephen O'Brien: I give way.

Mr. Speaker: Order. May I say to the hon. Gentleman that it is helpful to me and the House to know to whom he is giving way? Is it the hon. Member for Salisbury (Robert Key) or the hon. Member for East Devon (Mr. Swire)?

Stephen O'Brien: Thank you, Mr. Speaker. I give way to my hon. Friend the Member for East Devon (Mr. Swire).

Mr. Speaker: I am grateful. Mr. Hugo Swire.

Hugo Swire: I am most grateful, Mr. Speaker. Does my hon. Friend agree that it is important that PCTs see dementia as a priority? In the NAO report on the NHS operating framework for 2010-2011, the office's director of health value for money Karen Taylor said that trusts would concentrate on other issues if they were not made to focus on dementia. Is not that a fundamental flaw of the present Government's strategy?

Stephen O'Brien: That is precisely the problem that arises when something is called a priority but is not then backed by action. It is why we have the motion before us today. Most importantly, we already have the evidence of what happened with the national carers' strategy, given that the Princess Royal Trust has said that it could not find out where the £50 million for this year had gone.

Robert Key: The collective amnesia of Health Ministers is remarkable. My hon. Friend will remember that about a year ago my distinguished constituent Sir Terry Pratchett led a delegation to No. 10 on behalf of the Alzheimer's Research Trust. We met the Prime Minister and the Minister of State, the hon. Member for Corby (Phil Hope), who is in his place. The Prime Minister, the Minister of State and the good and the great of the dementia strategy who were present said that the Government recognised that this was a finite, predictable problem that they would address. They have not done so. They have failed to get the money to where it is needed, whether that is training people in hospitals to cope with dementia patients in there for other reasons, or helping the voluntary sector to provide vital services.

Stephen O'Brien: I am grateful to my hon. Friend, who has always taken a keen interest in this important area. He is right to remind us about the visit of Sir Terry Pratchett, not least because that followed his address to the Conservative party conference's main hall debate about dementia and how we must care for our elderly population. We were very pleased to see that that had been followed through with an invitation to 10 Downing street. Indeed, we wish to see the earnest of what was discussed there translated into action.

Jeremy Wright: The Secretary of State asked my hon. Friend whether dementia should be part of the NHS tier 1 priorities. Does he agree that that was an odd question, given that dementia does not feature specifically in any of the Government's tier 1, 2 or 3 priorities?

Stephen O'Brien: My hon. Friend is an expert in this subject and fully understands the difficulty that that entails. Most importantly, he recognises the priorities going forward. If we were to be given the chance to do so, we would look very carefully at the preventive agenda under the public health budgets. We would also ensure that the priorities are given to the NHS board, thus avoiding the target-based strategy that the Government have manifestly failed to deliver.

David Blunkett: Will the hon. Gentleman give way?

Stephen O'Brien: With respect, the right hon. Gentleman, who intervened earlier, should wait until I have made more progress. I will give way to him later.
	The most important thing is to recognise that, in addition to the four criticisms that I outlined earlier, the Government have also made an announcement about memory clinics. I hope that the Secretary of State will tell us what is going on with the memory clinics that were promised in every town. How many towns does he think that there are in England, and how many currently have such clinics?
	Despite reams of questions from me and other Opposition Members-

John Mann: Will the hon. Gentleman give way on that?

Stephen O'Brien: It is interesting that the hon. Gentleman seems to have a question about every single point that I am making. I shall come back to him, if I may, after I have made sure that the Secretary of State is aware of what I am saying. Despite questions from Opposition Members on the budget for memory clinics and the number of staff expected to be employed to deliver them, the Government could only answer:
	"Decisions about the nature, number and funding of the memory clinics will be made locally by primary care trusts, depending on local circumstances."-[ Official Report, 23 February 2009; Vol. 488, c. 202W.]
	What sort of a promise is that? The question for the Secretary of State today remains this: what is the precise number of planned and existing memory clinics and how many specially trained staff are there in the country?

John Mann: I thank the hon. Gentleman for giving way. I discussed memory clinics, among other issues, with my PCT last week. Nottinghamshire's Tory county council has privatised care homes in my constituency and elsewhere, with the result that day-care services will go, among them day-care memory clinics. Does he agree with that approach? Is it what we will see should he ever be in power, or would he adopt a different approach? We want to know.

Stephen O'Brien: I note that the hon. Gentleman did not answer his own question about whether there were any memory clinics in his constituency's towns. It is vital that he applies that scrutiny to his Government's policies. This debate is taking place because the Government have to be held to account.

Angela Browning: I am a member of the PAC, and we took evidence on this issue on Monday. However, another issue arose that cannot wait-the appointment of dementia champions. We asked the civil servants before us how many of them there were, and where. They could not answer, although I believe that they will respond in writing to my hon. Friend the Member for Gainsborough (Mr. Leigh). The practical implementation of many aspects of the strategy does not need to wait and the Government can get on with that. Having dementia champions in PCTs and hospitals saves money and introduces the efficiency savings needed to implement the strategy.

Stephen O'Brien: I am grateful to my hon. Friend for that excellent point. It is an example of how we need make sure that people at the front line get actions rather than words.
	It seems that the Government have got into a habit of making unfunded pledges of late. Not only was their dementia strategy riddled with spending loopholes, but the Minister's announcement last week of safeguarding vulnerable adults boards for every local area was equally vague about where the resources to implement the boards would come from. He made no mention of how the boards would co-ordinate with the dementia strategy, despite dementia sufferers being some of the most vulnerable people in our communities.
	I hope that the Secretary of State will take this opportunity to explain why he claimed in a statement last week to be implementing a system of registration for home care workers with the General Social Care Council, when the GSCC has informed some of its stakeholders that plans for the system are actually on hold. Clearly, the Secretary of State is too busy trying to bolster his party's manifesto to worry about making sure that these ambiguous claims are given the necessary detail, and the action points that have been highlighted.
	Last week, we uncovered figures on malnourishment in our hospitals. The problem has not been dealt with, despite repeated pledges from Ministers. Evidence shows that it is the elderly who are most at risk from malnourishment in hospital, as they are often unable to express their needs to nurses. Over the last three years, I have been hammering away at this outrageous and scandalous issue. We need only look at the new year press coverage of the widespread unnecessary tube-feeding of the elderly in care homes-particularly those with Alzheimer's-to see the harm that can be done to patients if the caring professions are under-equipped to meet the demands of dementia, both in terms of training and resources.

John Mann: Will the hon. Gentleman give way on that point?

Stephen O'Brien: No, I will not give way to the hon. Gentleman any more. He is clearly rather excited.
	The Royal College of Physicians undertook a review of tube feeding and deplored the practice as "completely unethical". That the Government is content to let the elderly and Alzheimer's sufferers be subjected to such appalling treatment as a result of overworked and under-trained care home staff is simply unacceptable. The Government have been sitting on the report of the nutrition action plan delivery board since July last year. I am glad that the amendment states that it will be published "shortly". Given that it is six months overdue, I hope that the Minister will undertake to publish it tomorrow.
	If the unnecessary tube-feeding of the elderly was not enough of a wake-up call for the Secretary of State, in November, the Government published a report overdue by 10 months on the inappropriate use of anti-psychotic drugs to treat dementia patients. Such drugs have a number of serious side effects that pose a particular risk to the elderly. They make patients unsteady and increase the risk of falls, they cause individuals to become socially withdrawn and they can accelerate cognitive decline, exacerbating the effects of dementia. Can the Secretary of State tell us what, if any, action has been taken as a result of the report? After three months, and after an initial delay of a year, all that the Government have done is appoint a national clinical director this week, although that is a welcome move.
	It is a sobering thought that the suffering of millions could be prevented if we found a cure for dementia. That might or might not be possible in future, but today anything that can be done to slow the onset of the disease is to be encouraged and welcomed. The Opposition believe that the Government should not resign themselves to the status quo but press ahead in support of research into new treatments for Alzheimer's, which is why we pledged in 2007 to increase the proportion of research budgets for work on dementia. Our policy has put Ministers under pressure to focus the Government's attention on dementia, and I was pleased see that in November, a new ministerial group was launched to support dementia research and to help increase the proportion of the Government's £1 billion research budget that is assigned to dementia research.
	Hon. Members will be aware of the concerns recently expressed by third sector groups that the Personal Care at Home Bill will hit those research budgets very hard. I have secured a categorical commitment from Ministers that that will not be the case, but until the details of where the money is coming from for the Bill are completely disclosed, inevitably the third sector will continue to raise those concerns. Will the Secretary of State undertake to place in the Library detailed accounts to show where the money is coming from?

Chris Ruane: On where the money is coming from, the hon. Gentleman will be aware that the health budget has risen from £32 billion to more than £100 billion over the past 13 years. Dementia services are an important issue, so can he guarantee the funding that will be available if he is fortunate enough to become a Health Minister in May or June this year?

Stephen O'Brien: It would be very nice if the Government would match our promise and say that there will be real-terms increases to the NHS budget going forward. It is an interesting point to be made by someone from Wales, which is a devolved region. My constituency borders Wales, and my constituents are aware of the differences between health services in Wales and services in England.
	Investing in high-quality research is a vital step towards discovering new and better dementia treatments. However, making drugs available to the wider population, to people who have just received a diagnosis of dementia, and to people with advanced dementia already in need of full-time care, is an altogether different challenge. Uniquely, we have pledged to change the remit of the National Institute for Health and Clinical Excellence to include a calculation of the wider societal costs of a given treatment when undertaking NICE appraisals. It is clear that dementia, as with other diseases, has an impact on local authority budgets and on public spending as a whole. Along with our commitments to value-based pricing, and to streamlining the NICE process, that will pave the way for dementia sufferers to access better drugs.
	We need to offer those who are faced with a diagnosis today, and those for whom a cure may not be found for a number of years, the chance to guarantee their care needs so that they can be reassured that whatever the impact of dementia on their lives and their loved ones, they will be able to access residential care should they ever require it. I have explained to the House before the merits of our home protection scheme, and the careful calculations behind what we have promised. It was designed precisely to meet those concerns and allay the fears first raised by Tony Blair 13 years ago about a need that has remained unmet over a period of Labour government. People can now look forward to a Conservative Government delivering a well-designed scheme that deals with people's fear of going into residential care. We need to look at the context of social reform-

Andy Burnham: Will the hon. Gentleman give way?

Stephen O'Brien: Of course. Perhaps the Secretary of State can answer the same question.

Andy Burnham: If that is the hon. Gentleman's big idea, can he explain how that will possibly help people who want to live at home with their family in the community, and not receive care in a care home?

Stephen O'Brien: The Secretary of State knows that that intervention was completely unnecessary, because it has never been claimed that it would help people to stay in their home. The idea is to meet the fears of people who have to go into residential care, by making it affordable and so that we do not discriminate against those who cannot afford it. It would not have the perverse incentive that he suggested, because of the national assessment criteria on care needs. The Prime Minister's knee-jerk reaction in the Personal Care at Home Bill did nothing to address that issue, and deliberately discriminates against people who need residential care. Doubtless that will be debated in the other place on 1 February.

Hugo Swire: What my hon. Friend says about the proposal is interesting, because in my constituency of East Devon, we are dealing with the case of Mr. Mejor, a former Spitfire pilot, which has attracted national attention. His care is being reassessed at the moment. His daughter is his carer and he has an elderly wife, but they may have to forfeit their home. Such isolated cases are becoming increasingly prevalent around the country, but they could be avoided if we adopted Tory policies.  [ Interruption. ]

Stephen O'Brien: I am grateful to my hon. Friend.

Angela Browning: On a point of order, Mr. Speaker. Is it in order for a Minister from a sedentary position to accuse my hon. Friend the Member for East Devon (Mr. Swire) of being ignorant? Is that appropriate behaviour for Ministers in the House?

Mr. Speaker: On the whole, I have good hearing. I must admit that I did not hear that remark.

Hugo Swire: I did hear it.

Mr. Speaker: Order. I am grateful to the hon. Gentleman. I was not disputing the word of the hon. Member for Tiverton and Honiton (Angela Browning)-I was simply making the point that I did not hear it. What I would say-and I am grateful to her for her point of order-is that it would be a good thing if the House settled down. I know that this is a highly charged matter on which strongly held views are being expressed, but that must be done in a seemly way that will command the respect of the country.

Stephen O'Brien: It is indeed a serious subject, Mr. Speaker. I am grateful to my hon. Friend the Member for East Devon (Mr. Swire) for raising a case that has become widely known. Our reforms would enable his constituent to be better served and to receive the care appropriate for his needs.
	To summarise, the issue of how we provide sustainable and affordable options for residential care is part of a wider debate on social care reform. The Government have played fast and loose with the challenge of reforming social services. Despite promises made in 1997, they ignored their own royal commission and, indeed, the whole problem, until 2008. We have had a vague Green Paper following an even vaguer consultation which has, in Lord Lipsey's words, been blown out of the water by the Prime Minister's announcement of free personal care late last year.
	Having rushed the Personal Care at Home Bill through the House, the Government have still not given any assurances on the costings of the Bill, or its robustness in the face of a potential legal challenge under the Human Rights Act 1998. Nor will the Bill help any of the significant number of dementia sufferers already in care homes. With the Secretary of State keen to make the Bill a top-three issue in Labour's election campaign, the House would do well to acknowledge the fact that dementia sufferers and, indeed, all older people with care needs, deserve more than political posturing on something that has not yet been properly costed.
	I hope that the Government will treat today's debate as an opportunity to discuss how we can work together to ensure that the public reap the benefits of the dementia strategy through action on the ground, and to reflect on how we build on the strategy to meet the demands that dementia will inevitably make on our health service in the coming years. We need such action, rather than words, and the Government must act quickly. It is time for Government to step up to the challenge posed not only by this devastating disease but by an unreformed social care sector, not with words or another vacant pledge, but with action at the grass roots of the NHS and social services and a concerted leadership effort at the helm of Government. A national care service does not simply come about or, indeed, become a national service simply by our using those words. It is important that the Government answer serious questions about provision, portability and, not least, who will pay. We are not just talking about the prioritisation and allocation of funding within the health budget. We are talking about supporting the work that funding enables: offering tailor-made training to staff at the front line; researching a cure; ensuring that the public have easy access to the best drugs on the market; and enabling all older people, no matter what their care needs, to guarantee their residential care in old age. All that will greatly enhance the quality of life for those diagnosed with dementia and for all elderly people seeking dignity and security in old age.

Lindsay Hoyle: I thank the hon. Gentleman for giving way. He is extremely generous. Does he also believe in the establishment of memory centres?

Stephen O'Brien: The Government announced the establishment of memory clinics, rather than memory centres, in every town. That has been amended, on occasion, to memory services. Clearly, what matters is not the building, but the training and the skills of the people offering all the NHS and care services, who need upskilling so that those services are better known by all who come into contact with patients. That will enable them to deal with many who remain undiagnosed, which was one of the earliest points made in the debate.
	The issue of dementia and the challenge posed by our ageing population cry out for leadership. It is one of the greatest and completely known and predictable challenges for our political generation. I urge all Members across the House to come together on the issue and to make the difference for some of the most deserving and vulnerable people by supporting the motion.

John Mann: On a point of order, Mr. Speaker. When the House adopted the Nolan principles and rules, which it did by resolution, there were two specific requirements on hon. Members, were they to receive finances or other assistance from outside bodies. The first was that the interest should be registered, which is signified by the letter R by convention and has been done in a fairly widespread way. The second is more important.
	The second Nolan rule adopted by the House, as I recall, is that for 12 months after receiving such money, the Member is not able to initiate any legislation whatsoever that impacts directly or indirectly on the recipient of that money. It is my understanding that a company called Care UK donated £21,000 to one of the signatories to the motion. If that were the case, can you confirm that it would not be in order for the motion to go forward?

Mr. Speaker: I am grateful to the hon. Gentleman for his point of order. I will respond as follows, and I hope this is helpful to the House.
	First, of course, responsibility for the registration of interests rests with individual Members. Secondly-I listened very carefully to what the hon. Gentleman said-if any Member has anxieties or is discontented about the conduct of another Member, the Member who is dissatisfied should complain to the Parliamentary Commissioner for Standards. At this very tense and competitive time, I should hope that Members would not air these matters on the Floor of the House when they are matters not for the Chair, but for the Registrar of Members' Interests and the Parliamentary Commissioner for Standards.
	If Mr. O'Brien wishes to respond to the point of order, he is welcome to do so, but he is not under any obligation to do so.

Stephen O'Brien: I am happy, Mr. Speaker, to take the opportunity to say that that is an extraordinary thing to be raised as a point of order, as you somewhat indicated. I can assure you, and through you the House, that any money that has been received by the office of any right hon. or hon. Member, particularly in opposition, to support their parliamentary work and particularly in relation to research, has been fully, openly and transparently declared at all times with the Electoral Commission and with the Registrar of Members' Interests, on time and in proper conformity with all the rules, and that no possible conflict of interest could arise.

Mr. Speaker: I am very grateful to the hon. Gentleman. The point of order has been raised. The response has been made. I hope that if it is pursued, it will be pursued elsewhere.
	Before we proceed, I should like to say that the hon. Member for Eddisbury (Mr. O'Brien) gave way generously in the course of his contribution. I am sure that was appreciated by the House. This is an Opposition day. There is another debate to follow. Several Back-Bench Members wish to speak in this debate, and I hope that further Front-Bench contributions will be tailored accordingly.

Andy Burnham: I beg to move an amendment, to leave out from "charities" to the end of the Question and add:
	"welcomes the Dementia Strategy launched in 2009 which contains a programme of work to transform services for those with dementia over five years and is backed by funding of £150 million over two years; notes that the Government will shortly publish the report of the Nutrition Action Plan Delivery Board; rejects the use of tube feeding on any grounds other than clinical need; welcomes the independent clinical review of anti-psychotic drugs which contains recommendations for the reduction in the use of these drugs for people with dementia; further welcomes the appointment of a National Clinical Director for dementia to promote better care and provide leadership for the implementation of the strategy; welcomes the creation of a ministerial group to develop dementia research; recognises that the enactment of the Personal Care at Home Bill will help some 400,000 people with the highest need; supports the Government's proposals to create the National Care Service, the first national, universal, entitlement-based system for care and support in England; and acknowledges that the Government's Dignity in Care campaign is working to engage local people in a social movement and to put dignity of those in care at the heart of services."
	It is hugely encouraging that today the House is again debating the care and support that we provide to older people, particularly those with dementia. Let me start on an uncharacteristically non-partisan note by congratulating the Opposition on calling today's debate. This is the third occasion since the publication of our Green Paper that we have debated these issues. Since then, we have also passed the Personal Care at Home Bill.
	In its long history, the House has never given such focused attention to this subject, which in time will touch the lives of all our constituents and arouses such raw feelings among those families most affected. When I introduced the Green Paper to the House, I said that we wanted to build an unstoppable momentum for reform of social care in England. It is beginning to feel that we are now getting close to achieving that momentum, but we need to do more. As the hon. Member for Eddisbury (Mr. O'Brien) said, we must build confidence among patients and carers groups, which have done such wonderful work in raising awareness of these issues while the political spotlight was elsewhere, that this time we are serious about change.
	In these debates, I have often used general national figures to illustrate the challenge and the nature of the ageing population. Today, I want to share with the House some stark figures presented to a meeting that I attended in Wigan last week. This local presentation of figures puts things in a sharper focus. In the Wigan borough today, 49,700 people are aged 65 and over, and 5,200 people are aged 85 and over. In just 15 years, those figures will have increased to 63,900 and 9,300 respectively. Twenty years from now, there will be 75,500 over-65s and 11,900 over-85s.
	If we leave the current unfair system to cope with demographic change in my constituency in the Wigan borough, it would have three social consequences. First, more older people in Leigh would be living in a more vulnerable condition with their personal care needs not being adequately met, placing a strain on other public services, particularly the local NHS. Secondly, a generation of older people in Leigh who, as in many former mining areas, are the very first in their families ever to own their properties outright, would be asked to draw on those assets to pay for care in old age, with the most unfortunate standing to lose all they have worked for. Thirdly, more people in Leigh would have to act as informal carers under even more strain as public support is spread more thinly, and would face an ever bigger battle to get help from the support system.

Lindsay Hoyle: I understand my right hon. Friend's commitment to his constituency, Leigh, and his use of statistics from there. Will he drop over the border and visit the important constituency of Chorley in Lancashire to see the need for a memory clinic there and the benefit that it would bring Chorley and its constituents? Will he come early and support that?

Andy Burnham: Chorley is just over the border and I would be happy to do that. Across the north-west we have seen real demographic change and a break with the past. In many communities in the north-west, people of the older generation were living in social or council housing. Today we have a generation of pensioners who have worked for and own their homes outright. It is my argument that if we leave the system unreformed, the unfairness felt by that generation will be far greater than anything we have seen so far. That is a key part of my argument for change. I would be happy to talk to my hon. Friend's constituents about how they see the issue and how it would affect them if we failed to act this time.

Bob Spink: May I raise a pragmatic point with the Secretary of State? Does he agree that people who need adaptations such as showers or stair lifts in order to continue to live in their own homes with dignity and independence should be able to get those without having to wait for months and sometimes even years? Can we address that point? By spending just a little money, we would save much greater sums in the longer term and give those people dignity.

Andy Burnham: The hon. Gentleman raises an important point. We have all probably seen in our constituencies how the disabled facilities grant has been stretched and has had to go round an ever-increasing number of people. In a constituency like mine, where there are lots of traditional old terraced properties, those properties need adaptations if they are to be made fit for purpose to enable people to get around. He is helping me to make my point. I am prepared to say that more money should come from my budget to invest in those homes to give people the support that they need. If we do not make that investment, the end result will be the national health service seeing those people in the accident and emergency department because they are not being adequately helped at home. That is the argument that I am advancing with some passion.

Bob Spink: rose-

Andy Burnham: I give way to the hon. Gentleman again, albeit briefly.

Bob Spink: Will the Secretary of State confirm that councils can add their own money to the disabled facilities grant, if they wish? They should not just hide behind the Government grant.

Andy Burnham: That is true, and we need a different approach, whereby all public bodies come together and think about prevention and the promotion of independent living in the home and the community. The hon. Gentleman is absolutely right to make that call.

John Mann: All public bodies should come together. Will my right hon. Friend comment on Tory-run Nottinghamshire county council, which, in its budget next month, proposes to cut 20 occupational therapy posts? They are precisely the people who need to make the DFG assessment, which is a statutory requirement of councils, and, should the council's cut succeed, it will automatically lead to more delays in my constituency.

Andy Burnham: Given that my hon. Friend has been determined to raise that issue three times, somebody ought to comment on the situation in Nottinghamshire. The Opposition studiously avoided it. Conservatives councils, by their actions, do something very different from the fine words that we heard delivered at the Opposition Dispatch Box not only in my hon. Friend's constituency; they do something very different locally, and we should inform people of what is going on there.

Hugo Swire: Most of us in the Chamber are signed up to the idea of independent living, whereby people should be allowed to stay in their own home if they want to, for as long as possible, but does the Secretary of State not agree that there is an inherent danger in that? Care packages become critical for those people, and they should receive a holistic care package so that they do not become isolated in their own homes, which can and does happen.

Andy Burnham: I agree with the hon. Gentleman, who makes a very important point. It would not be right for people to live in their homes without the necessary support, or when they were too vulnerable to do so, but he seems to be making the argument that I made to the hon. Member for Eddisbury (Mr. O'Brien) a moment ago. I said that we should introduce public support to help people live independently, because that is what they want, whereas the hon. Gentleman said that the right policy response was to cover costs for people going into residential care. I fear that that policy, which he and his colleagues have advanced, would create an incentive to push older people too early into care establishments and not give them the support to cope at home. Once care is free in a home but not in the community, it must create an incentive for people to enter care prematurely.

Hugo Swire: None of us wants people entering care prematurely, but the Secretary of State needs to distinguish between those who are elderly and those who have some form of dementia, because if they do not have carers who can care for them at home, by definition they will be driven into residential care at some point.

Andy Burnham: We do make that distinction, and we do distinguish people's needs in the care system. I agree with the hon. Gentleman; I do not wish to disagree with him on that point.

Madeleine Moon: Does my right hon. Friend agree that there is a huge risk in labelling people with dementia as unable to cope at home? In our desperate desire to protect older people, it is possible to say that because someone has dementia and diminished capacities, they lack the right to make sound decisions for themselves. It is our responsibility, as far as we are able, however, to tailor our care packages to enable people to remain at home. We should not take the decision to remove a person's right to make that decision for themselves.  [ Interruption. ]

Andy Burnham: My hon. Friend makes a point of fundamental importance, and Opposition Members would do well not to mutter and chunter about it, but to think about it for a moment. As we face demographic change, we need to rethink our ideas about ageing and the quality of life that we give to people, and our preconceived prejudices about what it means for somebody to develop dementia in later life. That is why the Government's policy focuses on supporting people at an early stage and giving them that support so that they can maintain independence. Alongside that, we want to ensure that we work to change public attitudes to dementia and the lives that people can lead. I shall return to that point.
	I was describing the situation in Leigh and the social consequences that I predict from a failure to act to reform our social care system. There is a depressing prospect if we fail to face up to the scale of demographic change. Reform of our care and support system is long overdue. One good thing that could come out of the debate would be a commitment from all parties to introduce a reform Bill in the next Parliament. That would instil confidence in those voluntary groups in our communities which have long called for reform. I hope that the other parties will be able to make that commitment today.
	People with dementia would be some of the biggest beneficiaries of a fundamental overhaul of the system, but in advance of any reform we have been working hard to improve our understanding of dementia so that we can start immediately on improving services for people suffering with the disease and for their carers. Almost one year ago we published the first ever national dementia strategy, and since then we have been working to give it life-to bring dementia out of the shadows, raise awareness and set in train a system-wide process of change and reform.
	We now have an implementation plan, setting priority areas for health and social care in order to take urgent action and guide the process nationally and regionally. Regional baseline reviews were completed in the autumn, paving the way for detailed joint local dementia action plans to be delivered by March, and we have a strong governance structure, pushing forward changes throughout the system. Building on unprecedented levels of grant increases since 1997, we have allocated to primary care trusts £150 million-in excess of the impact assessment figures-to support that work and make the strategy happen; and, as changes to services must be locally driven, we have given PCTs the freedom to determine their spending based on local needs. We believe that that is the right approach.

Jeremy Wright: The right hon. Gentleman has dealt with the point about why he decided not to ring-fence that money, but will he deal with why he did not ask PCTs to report back on how they had spent that money, so that we could at least have ascertained whether they had spent it on what the Government had expected them to spend it on? The Government have not asked PCTs to report back on the strategy under discussion, and that is unlike what was done for the national end-of-life strategy.

Andy Burnham: That is a fair question, and we are conducting a spending audit, which will produce a report. I shall be happy to share with the hon. Gentleman the response from that exercise.

David Blunkett: I was very pleased to be in Leigh on Saturday, but I was not able to examine the services there, because I was at my right hon. Friend's 40th birthday party. Will he join me in thanking the Alzheimer's Society's chief executive, Neil Hunt, who is stepping down, for his work on raising the profile of Alzheimer's and for his contribution to the strategy? Will my right hon. Friend also confirm that the Opposition's criticisms of the actions of PCTs would be greatly exacerbated if the Secretary of State had no powers in that area, and if the Department of Health gave away its powers to a national health service board, remaining in charge only of public health?

Andy Burnham: I am grateful to my right hon. Friend for that comment, and it was wonderful to have him in Leigh on Saturday-even if he has now raised with the whole House the question of my own social care needs and mortality. He makes a very important point, and we will all want to pay tribute to Neil Hunt for his work on raising awareness of the truly devastating effects of Alzheimer's not just on the individual who develops it, but on the extended family who watch that terrible process unfold.
	My right hon. Friend, who is quite right to praise Mr. Hunt, makes a very important point that is starting to run through the debate. We regularly hear from the shadow Health Secretary and Opposition Members a critique of ministerial diktat. They say that everything that we have done over the past decade is flawed; that we are micro-managers; that we do not let people get on with the job; and that we set too many targets. The whole thrust of the hon. Gentleman's deputy's remarks was to query why we are not doing more of that. When I asked the hon. Member for Eddisbury whether he would do more of it by setting national requirements, he said no. I rather lost the thread of his speech at that moment. It was easy for him to posture to his hon. Friend the Member for Gainsborough (Mr. Leigh), the Chair of the Public Accounts Committee, but when it came to the crunch he did not have any answers at all.

Madeleine Moon: Does my right hon. Friend agree that one of the greatest steps that this Government have taken to improve the quality of care for those with dementia is the setting of national care standards under the Care Standards Act 2000, and that the requirement to focus constantly on the training and quality of staff and the quality of care has been a huge step forward that was totally missing from 1995 to 1997, when I was involved in domiciliary care provision for people with dementia?

Andy Burnham: My hon. Friend is absolutely right. The 2000 Act was groundbreaking. It was bitterly opposed by some, if not all, Conservative Members, but it was much needed. It changed what had been a fairly unregulated system into a system where clear standards were required. We have built on that change year on year. As she will know, we will soon require all providers of health and social care to be registered with the Care Quality Commission. This continuous drive for the improvement of quality and safety in the provision of all health and social care continues, and I am grateful for her support.
	On the national dementia strategy and the steps that we have taken to ensure that we see progress on the ground, improving services for people with dementia is highly complex, but as we reach the end of the first year of this five-year strategy, progress in planning is beginning to show improvements in practice. Let us take Croydon memory service, where people have doubled the number of dementia assessments and helped to overcome the stigma attached to the disease. Assessments at the service are carried out with the patient and the carer in their home to help to maintain their independence and quality of life. Or let us look at Wakefield, where staff are working to reach as many people as possible, as early as possible when they become ill, again trying to support them in their own homes. They are bringing together social workers, district nurses and community mental health staff to create the kind of strong, close teams that make all the difference to patients and their families who need that professional support. We want to see more of those services across the country. That is the answer to the point that the hon. Member for Eddisbury made about memory services. Forty demonstrator sites have been set up around the country to look at how dementia advisers and peer support networks can help families to get the support they need.
	We are also working hard to raise awareness of dementia-this addresses the point made by my hon. Friend the Member for Bridgend (Mrs. Moon)-and we will launch a public awareness campaign in March. That will be focused not only on reducing the stigma that comes with dementia and improving understanding of dementia but on encouraging people to seek help and information if they see the early signs of the disease.
	Last week, we had an important interim report on our national dementia strategy from the National Audit Office; I am grateful for the attention that it continues to give to this important matter. The report describes our strategy as "ambitious and comprehensive". It acknowledges the progress that we have made while rightly challenging Ministers to intensify our efforts. I welcome the report and take its recommendations very seriously.
	We must recognise that we are in the first few months of this five-year strategy and that change will not happen overnight, but there are actions that we are taking to improve things now. For example, we know that we need to do more to improve commissioning. New joint commissioning guidance was published in June last year, and that is now helping PCTs and councils to make the right decisions in their area. We know that we need to improve training, so we have commissioned Skills for Health and Skills for Care to look at training needs across health and social care and, where gaps exist, to address them in the work force development action plan. We also know of the need to find the local leaders to drive through this programme of change. The hon. Member for Rugby and Kenilworth (Jeremy Wright) was correct to lay emphasis on that important point. The recent Alzheimer's Society report on acute hospital care and dementia was very helpful in prompting the acute sector to give priority to dementia. I welcome that pressure and those voices calling for such change within our national health service-long may it continue.

Rob Marris: As regards voices calling for change, will my right hon. Friend resist any calls for privatisation in the NHS, as embraced by the Conservatives, who are playing footsie with Nurses for Reform, a privatising organisation led by Dr. Helen Evans; reportedly playing footsie with Care UK, a privatising agency; and have a leading MEP, Daniel Hannan, calling the NHS a "mistake"? Will my right hon. Friend condemn that and assure me that there will be no such privatisation?

Andy Burnham: I can certainly say to my hon. Friend that we are proud of our NHS. We also, though, value the contribution made by voluntary sector and private sector providers. We have read reports about donations given to the Conservative party; I do not know the rights and wrongs of that. However, I do know that it raises a question about the independence of policy making by its shadow Front-Bench team. Well over a week ago, I wrote to the right hon. Member for Witney (Mr. Cameron) to ask him to give me assurances that that independence is not compromised- [ Interruption. ] Well, we need to know. I asked what safeguards have been put in place to remove any perception of a lack of independence. If I had had a reply to that letter, perhaps I would have been reassured by now, but I have not-am I not owed one so that I do not need to raise this matter? My hon. Friend makes an important point. It is interesting to see the company that the Conservatives are keeping, particularly people who repeat the claims about the NHS being a Stalinist creation.
	I entirely support the NAO's recommendation for acute hospitals to identify their clinical lead for dementia by the end of March. We are making real progress, but there is a long way to go. I can tell the House that the Minister of State, Department of Health, my hon. Friend the Member for Corby (Phil Hope), who is responsible for care services, and I are putting a determined and relentless focus on these services to achieve the transformation that we want to see. To help us, we have Martin Green as our dementia champion for the independent sector, and only last week we appointed the first ever national dementia clinical director, Professor Alistair Burns. Alistair will take forward our response to the anti-psychotics review to implement all its conclusions and recommendations, leading to reduced use of these drugs in the management of dementia. He will lead on the national audit of services and the action plans that follow. I pay tribute to my hon. Friend the Minister, who has driven forward work in this area and, indeed, commissioned that review by Sube Banerjee.
	As we approach the first anniversary of the strategy's launch, I am confident that we are on track to deliver our goals. I have described the NHS and social care services that I want to see in the coming years-services that are high quality and efficient, preventive and people-centred. Providing effective early support for people with dementia is a vital part of that vision. We now have the evidence to show just how crucial early invention can be. The partnerships for older people projects helped more than 250,000 older people, enhancing their quality of life, improving local working relationships and providing efficiency savings for the entire health and social care system. The evaluation of the projects was published earlier this month. It showed that through early intervention, they cut overnight stays in hospital almost by half, cut accident and emergency attendances by just under a third, and cut clinic or out-patient appointments by more than 10 per cent. For every £1 invested in prevention, there was an average saving of about £1.20 in emergency bed days. In fact, it was found that there was a £1.40 saving for secondary and tertiary prevention and a 70p saving for primary prevention services. This shows that even well-being services can deliver efficiency gains. Taken together, that makes a compelling case for changing the way in which we spend health and social care resources, as the hon. Member for Castle Point (Bob Spink) rightly said.
	As we reform services, we must strive to give people more choice, convenience and control over their care, to put quality at the heart of our services, and to take more early, preventive action to keep them healthy and in their own homes, which is where the vast majority of people want to be. That is what our Personal Care at Home Bill is all about. Through this Bill, we want to provide support to more than 400,000 of the most vulnerable people in our constituencies, including people with dementia, to help those with the greatest needs, who require intimate personal care in all aspects of their daily lives. In many cases, they will already have paid significant sums out of their own pocket towards the costs of their care as their condition has deteriorated. Their family and carers will have faced considerable pressure in recent times as they have battled to get the help that they need or sought to balance the demands of their own lives with looking after a loved one. The Bill will provide powers for people to receive intensive support to prevent them from developing more serious needs. It will help them remain healthy and independent in their own homes and extend their quality years of life.
	The Bill has two clear aims. The first is to end the lottery in home care for the most vulnerable people in our communities, and the second is to pave the way for a bigger reform of social care in the next Parliament and the creation of a national care service. There has been a long process of reform since 1997. We have committed unprecedented levels of grant increase to fund investment in local council services, achieved real success in improving service quality and introduced radical reform to personalise services, including individual budgets that give people control over their own lives.
	However, we know that a more radical approach is needed. The people with the highest needs still face the greatest costs, and we now have a chance to build a better future for them. People need and expect health and social care services to work more closely together. They want seamless services, and they do not want to be passed from pillar to post before they receive them.

Rob Marris: Can my right hon. Friend confirm that one major reform that we have introduced, which has been little heralded, is that when one of a married couple has dementia, for example, and sadly needs to move into a residential care home, there is no longer a requirement for that couple to sell their home at that point? This Government changed the National Insurance Act 1948, effective from April 2009. The myth is still going around that if a man goes into a residential care home, his wife has to sell the house and move out, but that is wrong. That is no longer the case, which was a major and positive reform from last April.

Andy Burnham: My hon. Friend is right that a myth is put about that we have done nothing and that there has been inertia for 10 years. There has not. We have reformed our social care system to make it fairer and taken steps towards the fundamental reform that I am saying is necessary. He is right that the house is disregarded when two people are involved, and he will know that we have gone further and introduced the deferred payments scheme, so that if the other person goes into a care home too, the house does not have to be sold immediately during their lifetime; that can be considered later.
	Those are two important reforms that are glossed over by some. However, we want to go further, and that is the case that I am making today. On their own, those reforms are not enough. If we do not do more, we will face a generation of older people who experience greater unfairness as they approach care. As good as those changes were, I am prepared to accept that they will not do the job completely.
	The Government's vision is of a national care service that is fairer, simpler and more affordable, that is underpinned by national rights and entitlements, that ends the postcode lottery in care and that is personalised to individual needs. The vision is a system with quality at its heart, in which people get the care and support that they need wherever they are in the country. The national care service is about helping people live their lives in the way that they want to, putting their needs and wishes first, helping them keep up relationships with family and friends and live in their own homes as long as they can, and where possible helping them continue to work and contribute to their community.
	Reform of the care and support system and the shift towards prevention is the only fiscally responsible strategy for the long term, but it is also the only morally responsible strategy. I intend to publish a White Paper in the very near future setting out the future of care and support in England. We are working to improve the services that are available now and transform them in the years to come. As we take our first steps in this new decade, we are beginning to create the momentum that is necessary to deliver once-in-a-generation reform.

Greg Mulholland: I echo the words of the Secretary of State by warmly welcoming the chance to debate this important issue. I congratulate the hon. Member for Eddisbury (Mr. O'Brien) and his team on bringing the matter forward. This is a particularly important time to talk about this range of conditions-we need to remember that that is what dementia is-that have such an impact not only on the individuals who are unlucky enough to suffer from them, but on their families, carers and friends and on the communities that they live in.
	Here we are, nearly a year after the announcement and commencement of the national dementia strategy, which we all welcomed as a big step forward in how we, as a country, deal with dementia. It is right and proper that we now consider the matter and where we are up to, just before we get into the campaign proper, because whoever is in government after the next election must be firmly committed to seeing the strategy through its whole 10-year period. We are certainly happy to make that commitment, as I am sure Members of all parties are.
	The comments of Professor Sube Banerjee to the Public Accounts Committee were an extremely powerful way of describing the effects of dementia. He said that it was
	"one of those rare diseases that people actually consider worse than death."
	We all know that dementia is becoming more and more prevalent in our society. Already about a third of people in care homes suffer from it, and the latest estimate is that there are approximately 600,000 people with dementia in England. However, as the hon. Member for Rugby and Kenilworth (Jeremy Wright), who leads the all-party group on dementia, has made clear, we simply do not know the actual number. That is partly because of the challenge of early diagnosis and partly because of the challenge of getting people to present to doctors when they fear they may be in the early stages of the condition.

Lindsay Hoyle: The hon. Gentleman is making a very good point. May I say to him that there is a stigma among relatives, who want to protect someone in their family and do not want to admit that there may be a problem? Does he agree that we need to provide more help and support and welcome the job that carers do?

Greg Mulholland: I do, and that is a very important point. I hope that our regular debates on the matter and the strategy itself will do something to deal with that stigma. We can only imagine the trauma and devastation of someone facing the possibility that they or a loved one may be facing the condition, and the effect that it will have on their life in the coming years.

Madeleine Moon: Does the hon. Gentleman accept that part of the difficulty that we have, and part of what we must accept in the debate, is that dementia is not an entity but a spectrum? Someone may function quite well on one day but not on another. Depending on their medical condition, their situation may fluctuate. It is dangerous to write off somebody who has been diagnosed with aspects of dementia as "demented". We have devised the capacity assessment, but that should be utilised only in conjunction with supportive carers who know the individual and their fluctuation.

Greg Mulholland: I alluded to that in my introductory comments by pointing out that dementia is not one condition and that a number of conditions come under that umbrella, but the hon. Lady is absolutely right that dementia affects people in different ways. Many people in the early stages can lead full lives and can work. I have been pleased to work with the author Terry Pratchett, particularly on research into dementia, which, as Ministers will know, I have campaigned on. Terry Pratchett is still writing, going to our party conferences and getting the message across, and it is very important that we do that. Nevertheless, the fear and stigma will still exist, for Terry and for everybody else. They simply do not know what is around the corner, how it will affect them and how long they may live. The hon. Lady is right that that presents us all with a challenge in considering how to deal with the matter in the health and social care system.
	I echo the comments of the hon. Member for Eddisbury in paying tribute to everyone currently involved in dementia care, which is a particular challenge. Of course, the wonderful people who work in our health service and in our care homes always face challenges, but those who deal with the problems of people with dementia, particularly in the latter stages, deserve our tributes for all they do for those most vulnerable people in our society. I also echo the tributes to the all-party group, of which I am a member, and especially to the leadership of the hon. Member for Rugby and Kenilworth.
	The national dementia strategy for England was launched, rightly with a fanfare, last February. It made clear recommendations for improving dementia care under the key themes of raising awareness and understanding, of early diagnosis and support and of how to help people living with dementia. The National Audit Office report-HC 82-has now been published. Although it acknowledges that progress has been made in some areas, it expresses the concern that dementia services are not given the priority that they were promised a year ago-and, crucially, the priority that they need for the excellent strategy to take hold in the early stages. All hon. Members want that to happen.

Tim Farron: My hon. Friend has alluded to a concern that many of us share: although we welcome the funds that have been delivered through the national dementia strategy, the £1.5 million provided to the primary care trust in Cumbria does not appear to have resulted in any additional services for people suffering from dementia or for their carers. Organisations such as the Alzheimer's Society want clear, tangible, additional services to be provided for those people rather than the money being used simply to plug existing budget gaps.

Greg Mulholland: My hon. Friend rightly makes the point that making a difference on the ground, in those PCT areas, is important. Without getting into the ring- fencing debate, as we often do, can the Secretary of State give us better assurances and tell us that the money is being spent, simply by asking PCTs to report back and tell us what they are doing? Every PCT that has been given the money has a responsibility to ensure that it delivers. That is a challenge for PCTs, because of their budgets, but it must happen for the strategy to work. When there is evidence on the ground that the money does not appear to make a difference to local dementia services, sanctions must be put in place so that the Secretary of State can take action. If PCTs are failing to deliver the strategy, the Secretary of State-whoever he is-should be able to say that that is unacceptable and that it will not provide appropriate care in the area.
	Early diagnosis is one of the biggest challenges in the strategy. According to research from the House of Commons Library, people wait for three years, on average, before reporting symptoms to their doctor. That problem cannot easily be solved, but it is clear evidence that education must be a key part of the strategy, particularly through health professionals and GPs, to communicate to people that they should go to see their doctor and get a diagnosis. To revert to the point that the hon. Member for Bridgend (Mrs. Moon) made, early diagnosis and care from that stage can make a great difference to the condition's progression.
	The Secretary of State mentioned the concerns about local leadership. The point has been strongly made that local leadership is simply not there. Without that, the strategy will not succeed. It is not only about money, but about leadership. I urge him and the Minister to stick to the deadline of March-I welcome the fact that he has set it-for having it in place.
	We need further and appropriate meshing of our health and social care systems. It is a policy challenge to which there are no easy solutions, but interesting pilots are going on around the country. The artificial divide that often exists between health and social care cannot be more meaningless than in the case of dementia. It would be good if we could use the national dementia strategy to make progress on better meshing health and social care, so that the system becomes seamless for people, whether they need something that is currently defined as "care" or something that is defined as "health care".

Madeleine Moon: One of the key ways in which that joint working can be effective is when an elderly person with dementia, who has a care package at home from a care agency, needs to be admitted to hospital and the ward staff are willing to accept the help, support, advice and guidance of those carers from the agency, who know all about the management and needs of that individual. Sometimes there can be a breakdown of communication between professional care staff in hospitals and those at home. A greater willingness to listen to advice about the care to which people respond at home could result in treatment in hospital being eased.

Greg Mulholland: The hon. Lady makes an important point, which clearly shows that we need to learn from experience on the ground how we can improve matters. I shall speak shortly about the particular challenges of dementia care in hospitals.
	Training is another key part of the strategy. According to the dementia care services market briefing last year, a third of care homes that specialise in dementia-I am not referring to those that do not-do not provide their staff with dementia care training. When the Minister responds, will he give us an update on progress on training? If our care professionals-people who deal with those with dementia-do not have the proper training and education on dementia, many of the good aims in the strategy simply cannot be brought to fruition.

Nick Palmer: Does the hon. Gentleman agree that there are two kinds of care training: one for people who are engaged in intensive care support for those suffering from the illness and the other for general hospital staff, who may encounter patients who have another illness but who also have elements of dementia? The latter also need training in how to respond appropriately.

Greg Mulholland: The hon. Gentleman makes a good point, with which I agree. Anyone in the care or health sector who may come across people with dementia needs education and training about how to look after people with that range of conditions.

Hugo Swire: Does the hon. Gentleman agree that it is important to consider expanding the role of Admiral nurses, of whom there are 65 or 70 currently in England? The nearest one to Devon is unfortunately based in Woking, but they do a remarkable job, and the body should be expanded.

Greg Mulholland: That sounds like an interesting scheme, albeit one of which I am not particularly aware. Again, it is the sort of thing that should be fed into the strategy and the debate, so that we can learn from best practice throughout the country.
	The Alzheimer's Society expressed its disappointment, which I share, that the recently published operating framework for 2010-11 does not explicitly refer to dementia.

Andy Burnham: The hon. Gentleman is making an excellent speech, but to correct him, the recent operating framework mentions dementia services.

Greg Mulholland: The information came from the Alzheimer's Society. My point is that primary care trusts must view the services as important. The Government have set out their stall with the strategy, the Opposition have had a chance to set out theirs today, and I am doing it for the Liberal Democrats. However, if strategies do not filter down to PCTs, we will not have the services that we need on the ground.

Jeremy Wright: May I return briefly to the operating framework? The Secretary of State is technically right that dementia is mentioned, but it is mentioned extremely fleetingly, and the importance that the Government have given to it is not in any way reflected in the priorities of the strategy.

Greg Mulholland: I thank the hon. Gentleman for that helpful intervention. I do not want to get sucked into the rather bad-tempered debate about tiers 2 and 3. The national dementia strategy is clear in its prioritisation, but is that filtered through to all levels of the NHS, which it must be if it is to be delivered?
	It was promised that every town in the UK would have access to a memory clinic-that was how the promise was phrased-but it is clear from the NAO report that that will not happen. The hon. Member for Chorley (Mr. Hoyle) used a different word, and spoke of memory centres, but the hon. Member for Eddisbury spoke of memory services- [ Interruption. ] He pointed out that the rhetoric was now memory "services" rather than "centres" or "clinics". We need to be clear where that promise is going. Let us face it: what we are talking about is everybody in every town having appropriate access to specialist services to deal with memory dementia.

Lindsay Hoyle: Just for clarification, I treat a "clinic" and "centre" as the same-the provision of services is the important thing. Obviously, a major centre such as Chorley would be an ideal location.

Greg Mulholland: I am sure it is. I am sure that Chorley is the ideal location for many things- [ Laughter. ] To make a serious point, I was not trying to catch the hon. Member for Eddisbury out on the words that he uses; I am simply asking the Minister whether people in every town and city, including Chorley and Leeds, will have access to those services in the way that was promised.
	Funding is a challenge for us all. We recently had a good debate on the Personal Care at Home Bill, but care for people with dementia in itself presents a huge challenge within the overall discussions on funding for social care. Dementia already costs England alone £15.9 billion a year, which will rise sharply year on year. The King's Fund has predicted a total cost of £34.8 billion by 2026, which is an increase of 135 per cent. Dementia currently costs the country £539 a second. An amount of funding was clearly set out in the strategy-a figure of £2 billion over the years of implementation-but where precisely are we going to identify efficiency savings to secure that important funding? Without that, the strategy will fall by the wayside, so we must face that funding challenge.
	I say that within the wider context of the debate on the funding of long-term care, which I have been happy to be involved in. I have spoken many times in the House on that and have held many meetings with many of the organisations involved. Dementia funding is particularly complex, partly because it so clearly breaches the artificial divide between health and social care-there are huge costs for both the NHS and local councils. We also know that as life expectancy rises and care costs increase in total, families face uncertainty about what their costs will be and how best to plan for them. That is a challenge that we have yet to face.
	I welcome the Secretary of State saying that the White Paper will be published soon. I do not know whether he can commit to giving any more of a clue as to what "soon" means, but we are running out of time before we get into the campaign-there was a little too much campaigning in some of the earlier contributions-and in this Parliament.

Andy Burnham: By June.

Greg Mulholland: That is very helpful. You heard it here first, Mr. Deputy Speaker. If there is nothing by 3 June, we will be asking the Secretary of State to resign.
	To echo an earlier point, the Liberal Democrats are firmly committed to sitting down with both the Conservatives and the Government to find a process and a solution to the problem of funding for social care. We all need to commit to doing that in the next Parliament. The publication of the White Paper will be the time to start that process, but it will happen mainly in the new Parliament.
	On funding for dementia, the Alzheimer's Society has pointed out that dementia services provide excellent value for money, which is an indication that too often we do not consider the value of preventive care. In its 2007 report on dementia, the NAO highlighted that significant money was wasted because of an inadequate response to dementia, which we must take seriously.
	I am not going to discuss the debates on the Personal Care at Home Bill that took place two weeks ago, because the matter has been dealt with, but people with dementia, and certainly people who have dementia in its latter stages, are in the category of people who will receive care at home. However, many people with dementia are cared for by spouses, partners, friends or neighbours. I made this point in the debate on the Bill, although not specifically with regard to people with dementia, but many people may not be in the Government's figures and may not yet have come forward to say that their loved one qualifies for, and would like to receive, personal care at home. That is a note of caution, because the cost to local authorities may have been underestimated. We need a more robust assessment to include those who might wish to receive personal care at home who are not yet accounted for in the figures.
	When I first read the motion in the name of the hon. Member for Eddisbury and the Secretary of State's amendment, I was pleased to see that both contain a clear commitment to dealing with anti-psychotic drugs, which are sometimes known as the chemical cosh. My hon. Friend the Member for Sutton and Cheam (Mr. Burstow), who has led on that issue over a number of years, has highlighted that totally unacceptable and too-prevalent practice. According to the Alzheimer's Society report, 77 per cent. of nurse managers and nursing staff said that anti-psychotic drugs were used always or sometimes to treat people with dementia, which is huge figure. I hope it is decreasing, and it would be good to hear about progress.
	We want a clear commitment not only to review the use of anti-psychotic drugs, which is included in the amendment, but to stamp it out when it is not appropriate. Those drugs have been shown to shorten life, and slow response times, mobility and cognition-of course, they do nothing to treat dementia itself. People are up to three times more likely to have a stroke while under the influence of the drugs. It is frustrating that we are still talking about the matter in that way. I would like a little more from the Minister. Never mind a review; let us have action to stamp it out. Let us educate people and ensure that our most vulnerable people are not being inappropriately treated.
	Earlier in the debate, someone mentioned inappropriate treatment by the use of a feeding tube. We had the report earlier in the month from the Royal College of Physicians, which said that the procedure should be used only as a last resort, but was all too often being used inappropriately in care homes. The report suggested that the practice could be due to staffing constraints and budgets. Dr. John Saunders, the co-chairman of the working party, said:
	"In the demented patient it does not prolong life, the treatment is inappropriate and futile. It is actively unethical and dubious."
	I am sure that we all agree with that, but it is thought that up to a fifth of patients with feeding tubes have them inappropriately, because either the tubes are futile or the patient could eat normally if given proper care and assistance. It is an absolute scandal that that is still going on in care homes. I ask the Minister to respond on this point and tell us whether any progress is being made. I hope that he will be able to tell us that greater progress will be made.
	I was amazed to learn that it is estimated that a quarter of long-term patients in hospital have some form of dementia. The medical evidence shows that the longer people with dementia are in hospital, the worse the effect on their symptoms of dementia and on their general physical health. Of course, discharge to a care home or their own homes then becomes more problematic, and there is the danger that anti-psychotic drugs are more likely to be used.
	I join the right hon. Member for Sheffield, Brightside (Mr. Blunkett) in paying tribute to Neil Hunt for his leadership of the Alzheimer's Society, which has produced an excellent report called "Counting the Cost". Neil Hunt has said that the NHS is not facing up to the challenge of dementia and that there is a need to improve the care given to sufferers.
	The report finds that supporting people with dementia to leave hospital one week sooner than they currently do would result in savings of at least £80 million a year. Such an approach differs from the usual approach taken in health and social care, but we all need to identify such savings if we are to continue with the commitment to the national dementia strategy that we all want to see.
	The issue of research is not directly mentioned in the motions today, but I agree with the comments made by several hon. Members that, alongside the issue of care, we need to look at the issue of research. The cost to the NHS of dementia is more than that of cancer, heart disease and strokes put together, but the budget for research is a fraction of that for cancer. We need to listen to Terry Pratchett and the Alzheimer's Society and find ways to provide better care and enable people to function and work for longer through scientific breakthroughs. I ask the Minister for reassurance that we are making progress-even if it is only slow progress, given the recession-towards the £96 million research budget that the Alzheimer's Research Trust estimates is necessary to tackle this appalling range of diseases.

Nick Palmer: I have some personal connection with this issue. My late father suffered from dementia, and my mother and I were his carers until he died aged 75. Before I discuss general policy issues, I shall make a few extrapolations from my personal experience.
	I am aware that people are fearful of dementia, partly because it is not at present curable and partly because they fear many of the aspects that we have heard about today-the decline into incapacity and helplessness, and the humiliation. However, it is not always as traumatic as people fear. My father retained his optimism and good humour to the end. I like to remember his remark that the good thing about dementia was that he was able to read all his favourite books again because he could not remember how they turned out. If we can encourage that sort of attitude, among carers as well as sufferers, we might be able to make things less traumatic.
	An important policy point that arises out of that experience was raised by my hon. Friend the Member for Bridgend (Mrs. Moon), who referred to the spectrum of dementia, from serious cases, with sufferers who are totally dependent, to cases in which people are able to make decisions about their own lives. My father remained aware of his condition throughout his life and he was able to discuss with us appropriate protective measures and the trade-off between too much risk and too much interference with his enjoyment of life. For instance, he never went out on his own, because he was afraid that he would not find his way home, but that did not mean that he just stayed at home all the time. When he could, he went out to enjoy the pleasures of the outside world.
	The condition is not a steady state. People often imagine that once someone has dementia they experience a steady slide downwards, one day forgetting one thing and the next day forgetting two things, and so on. As my hon. Friend also pointed out, it is not like that. Sufferers have good days and bad days, just like the rest of us. It is important that carers, whether professionals or relatives, recognise the good days so that they can take a step back and be less intrusive, to give the sufferer a bit of space, a chance to explore what they can do and to use what capacity they have. On other days, the sufferer will need more support, and the carers will need to move in closer. That recognition can be difficult, and is part of the training that has been mentioned already today, especially in the sensitive speech by the hon. Member for Leeds, North-West (Greg Mulholland),

Hugo Swire: I am following the hon. Gentleman's speech with considerable interest. Does he agree that one of the problems for carers, especially family carers, is the unpredictability of the sufferer's response? That is why some form of proper respite care is so critical, so that carers have a chance to recover a piece of their own lives.

Nick Palmer: The hon. Gentleman is right. From talking to other families in that situation, I know that it is common for the carers to suffer much more than the sufferer, although that was not the case for my family. The person with the condition will sometimes have a diminished recognition of just how bad the situation is, but the carers can see something tragic going on, and it is important that they get support. An element of day care support is also important for the person suffering from the illness, which relates to the points made by my hon. Friend the Member for Bassetlaw (John Mann) about what is happening in Nottinghamshire.
	The general problems that we face include, first, the widespread dread of Alzheimer's and dementia, which we must anticipate will continue to increase as it seems to be a function of greater longevity. If someone dies at 40, they probably will not have Alzheimer's-they might, but the probability is much lower. If someone lives to 90, the probability is significantly higher. The excellent report by the Parliamentary Office of Science and Technology, on which we all often depend, states that 47 per cent. of the British population know of a family member or close friend with dementia. In a great many cases, therefore, that dread is fed by personal experiences. Indeed, I would assume that some of us in the Chamber will eventually fall victim to dementia. We need to be aware of that.
	On this issue, there is real public support for effective action so far as it is possible. I shall be partisan for a moment: as my hon. Friend the Member for Bassetlaw (John Mann) said, Nottinghamshire county council proposes to sell off all its care homes, including Bramwell, in my constituency, which specialises in Alzheimer's care. It has conceded, in discussions with me, that the effect might be to dissipate the centre of expertise that has been built up there, because the private buyer may choose to merge it in due course with another home and so lose that focus. That seems to be undesirable.
	In the local debate, a number of constituents have said that, although in other respects they are 100 per cent. behind the Conservative council and have always been Conservatives, on this issue they think that the council has got it wrong-to the point that they might not vote Conservative if it persists with its policy. We are all politicians, so this issue becomes partisan. However, even those parts of the electorate that are otherwise keen to save public money, by reducing council tax and so on, make an exception here; they feel that it is valuable to have some local centres of expertise, because any one of us or our loved ones could fall victim to Alzheimer's or dementia and so need such a centre. If we do not, and if we spend a bit of council tax on it but find that we do not need it, we should count our blessings.

Jeremy Wright: I will not, of course, engage with the hon. Gentleman on the details of what is happening in Nottinghamshire, which I do not know anything about. However, I assume from what he says that his case is not that there are not excellent examples of good quality dementia care in the private sector.

Nick Palmer: That is correct. I also would not say that every public sector home is a model in its treatment of Alzheimer's. I am basically saying that it is important that each area has available centres of excellence, and that that should be a responsibility of local councils. We can debate how they can achieve that, although to some extent that is a secondary matter, but they should not pursue policies that result in the absence of such specialist knowledge.
	The second general issue is the conflict between localism and national strategy. We tend to tiptoe around this matter; we all try to have it both ways. We are all in favour of localism and against postcode lotteries, but they are the same thing, are they not? If we have local decision making, we will get variations-one local authority will decide one thing, and another will decide something else, and for the sufferer, that will mean a postcode lottery. If they happen to live in an area where their condition-this does not apply just to Alzheimer's-is given greater priority, they are in luck. On the other hand, if we try to govern it all from the centre, the sense of local responsibility and local decision making is lost. There is a tension there that we have to be honest about, and I shall come back to that in a moment.

Stephen O'Brien: The hon. Gentleman has made an important point with which we are all wrestling: how one can put portability into effect, on the ground, so that if one had to move between areas, there would not be a postcode lottery-as he put it-in the delivery of services. I hope that he has something to say-he might have been coming to this-about how a national standard assessment of care need might look. The Government have yet to answer that important question.

Nick Palmer: I agree with the hon. Gentleman; that is an important point, although, to be honest, I did not include it in my speech notes. However, I am glad that he has raised it, because it will become increasingly important. Often, somebody with difficulties will move home to be closer to relatives able to give support. The continuity of support then is extremely critical.
	What should we be trying to do next? First, I would like to come back to my response to the hon. Member for Rugby and Kenilworth (Jeremy Wright). We need to develop and protect centres of expertise in each area. We can debate how large the area should be. In 2006, we had up to 131 memory centres-we probably have a few more by now-in England alone, I believe. That is a reasonable number. We can debate just how dense the network needs to be, but basically it ought to be possible for people in each area to have access to expertise. If, at some point, someone needs to go into a home, it should not be so far away that those who have cared for them until then can barely visit and so supply the support.
	I believe that this is one policy area in which it is appropriate to have a national target, if I may use the dreaded word. It is appropriate that the Government place an obligation on each county council to ensure that within the county there is at least one centre of expertise for Alzheimer's and dementia. If we do not do that, we will see what is happening in Nottinghamshire-under the pressure of costs and other considerations, councils will prioritise other matters. Centres of excellence are so important at the moment, partly because the limited support that we can give to those with dementia is an expert skill. The POST report states that the memory services that have been introduced have been shown to be "clinically and cost effective". It is one of the rare and precious elements in our approach where we have something that actually works, and unless we can apply it locally, people locally will miss out. It is appropriate, therefore, regardless of one's ideology in other areas, to say that the Government should require each county council to provide and maintain one such centre of excellence.
	If, and when, adequate or good treatment is developed for dementia-the pharmaceutical industry is making enormous efforts, because obviously it has an interest in finding a treatment-those centres will be all the more important. What a tragedy it would be were we suddenly to find that we had a treatment but had thrown away the infrastructure to deliver it and that in some counties we no longer had that expertise. Obviously we could build it up again, but in the short term we would miss out, and that would be a genuine tragedy for the people involved.

Jeremy Wright: I am grateful to the hon. Gentleman for giving way again. I wonder whether he agrees that the likelihood is that the treatment that he is talking about will not be deployed through the network that he is describing unless we spend more money on research. Would he like to comment on that?

Nick Palmer: Yes, we are part of the world community on that. It is entirely appropriate that Britain should play as full a part in research as it can. It might be that the important breakthrough will be made somewhere else and that we will develop it-that is the way things happen in medical research. Private research is intensive, because the first company to develop a treatment will do well out of it, and frankly I would not begrudge any company that success, because it would be doing a lot for humanity. I therefore accept the hon. Gentleman's point, but we should not create illusions either. Even if we can treat such conditions, it might be that as people live longer and longer, the prospect of our mental capacity on average gradually declining will inevitably be an invisible rider beside us. It might be that although we can alleviate the problem, we will never completely remove it.

Hugo Swire: I am grateful to the hon. Gentleman for giving way to me a second time. Does he agree that, alongside the advances in medical science, which we all hope will accelerate, part of the Government's national dementia strategy that deals with the training, the education and often the re-education of GPs in the early diagnosis of dementia in its first stages is also critical?

Nick Palmer: Yes, and I can see that the hon. Gentleman's brain is in an excellent state, because he has anticipated what I was about to say. My next point was that we need to educate GPs, the public and non-specialist health and social care staff to recognise and respond to the signs of early onset, and to distinguish accurately between normal absent-mindedness, which is not totally unknown even in this place, and the clinical symptoms of dementia. I see that both ways in my constituency work: I see people who are convinced that their partners have Alzheimer's when they perhaps do not and people who are shutting their eyes to it. Because we know that early recognition combined with memory services can delay the need to enter a care home, it is a cost-effective approach, which is important to the individuals affected.
	As an immediate measure, we need to help people to stay at home while they can, if they want to, with support for their carers-this relates to the point that the hon. Member for East Devon (Mr. Swire) made earlier. For most sufferers, there is a trade-off between the risks of being at home in a less guarded environment than a closed mental illness institution and the benefits of being in a familiar environment that they have cherished for many years, surrounded by people they know-and hopefully love-and of drawing comfort from that environment when their facilities diminish. We should not take away that choice.
	We are very risk-averse as a society. If somebody with dementia who lives at home has an accident-because they wandered on to the streets, got lost and were knocked down by a car, for instance-there are always questions asked. People ask, "How could that happen?", "Where were social services?" and "What were the relatives doing?" However, there are risks in every part of life, including being in a closed ward. There are risks to people's mental state and, basically, their happiness, so we should not take away people's capability to make rational decisions just because their memory is failing. In many cases it might be possible to have a serious discussion about that. The Personal Care at Home Bill is an important contribution to that, because if free personal care is available at home in the most critical cases, in many instances it will tip the balance between early admission and admission a little later. That will not only help to reduce costs, but be beneficial for the individual concerned.
	Finally, what is our long-term vision? In the long term, we hope to see effective treatment. Perhaps we will never have a complete cure for mental decline, as I have said, but we should aim for a continuous spectrum, which starts at the point at which the first symptoms are recognised and accepted as a normal part life-as one of the things that can happen when one gets older-in order to ensure that initially relatives, friends and carers are brought to accept what is happening as something natural that they can deal with; that if and when the symptoms start to get worse, there is additional care support from the local authority of the kind envisaged in the Personal Care at Home Bill; that if that person's condition continues to deteriorate, we have day care facilities and support for carers, so that that period is less traumatic than it often is today; and, if that individual eventually needs to go into a care home, that the home still treats him or her with the respect and dignity that he or she deserves.
	My father said in his final years that he had never been happier. I would like to think that in future that would be true for the majority of sufferers.

David Tredinnick: I am grateful that you have called me, Mr. Deputy Speaker. I feel that it would be churlish if I did not congratulate the Secretary of State on his 40th birthday, although sadly he has now left the Chamber.

Phil Hope: I will pass it on.

David Tredinnick: I am grateful to the Minister. The right hon. Member for Sheffield, Brightside (Mr. Blunkett) mentioned the Secretary of State's birthday and also said-the Minister will perhaps correct me if I have got this wrong-that they were in Wigan. I remember reading a book about Wigan by George Orwell-"The Road to Wigan Pier"-my abiding memory of which was the tripe shop, whose tripe was described by the proprietor as being the most beautiful tripe in the world. The author goes on to describe the number of flies that infested that tripe, so I was thinking to myself, "I do hope that the Secretary of State didn't have a meal of that quality in his hometown," although no doubt things have improved a lot.
	I would like to focus on dementia this afternoon and, in a spirit of co-operation with the other side in the House, say how much I agree with the Secretary of State that this was a most appropriate debate for my hon. Friend the Member for South Cambridgeshire (Mr. Lansley), the shadow Secretary of State, to have chosen.

Nick Palmer: indicated assent.

David Tredinnick: I see the hon. Gentleman nodding his head. This is an important debate at an important time. I do not want to speak for very long, but I would like to cover some of the problems and talk about Leicestershire and some of the possible solutions, because we have heard about aspects of care, but not a lot about the solutions for people who have the condition. I therefore hope that I can add something.
	I echo the earlier remarks of my hon. Friend the Member for Salisbury (Robert Key), who talked about amnesia, not dementia. The Government's attitude to this subject has something in common with their attitude to energy, in that they appeared to suffer from amnesia in their policy on both dementia and energy for about the same length of time. For about 11 years, we did not have an energy strategy, and we certainly did not have a dementia strategy. It is amazing that the Government could have been in power for so long and then, as it were, stumbled across the issue so late in their tenure of office, which many of us suspect is almost over. The Minister of State is shaking his head, so we had better not go down that route, Mr. Deputy Speaker. Indeed, I can see you shaking your head, too. We have had various statistics-

Mr. Deputy Speaker: Order. I was shaking my head about not going down that route, not about other matters.

David Tredinnick: Thank you, Mr. Deputy Speaker.
	The figures show that nationally there are about 700,000 people with dementia, but the number will double and rise to about 1.5 million. In Leicestershire, the county I represent, the figures for 2008 were about 8,000, and by 2025 it is reckoned the number will be 14,000. In my constituency, the Hinckley and Bosworth figures are 1,231 for 2008, rising to 2,114. There is no doubt about the scale of the problem. It is not surprising given that we have an ageing population.
	One of the key problems is the mismatch between the availability of funds and those who are required to supply the services. I hope to develop that point. Conservative-controlled Leicestershire county council has done a very good job in that respect, but it has not been provided with the funding that would have been reasonable to supply the services it wants to offer.
	I shall not try to cover everything. When I first came into the House, I remember a senior Member telling me-about somebody else's speech-that there was too much pudding in it. Three points in a speech is probably a good thing, particularly when other Members want to speak. My last point is about the negative impact of anti-psychotic drugs. The issue was also raised by the Secretary of State and commented on by the hon. Member for Broxtowe (Dr. Palmer), the hon. Member for Leeds, North-West (Greg Mulholland), who is no longer in the Chamber, and others.
	Anti-psychotic drugs can cause strokes and they can cause elderly people to fall. I very much welcome Professor Sube Banerjee's review of anti-psychotic drugs. The Minister may say something about it later on, as he was prompted to do so earlier. It is a major issue and I hope to suggest some other products that might help in such cases, although I have to be careful as I may be corrected by the doctor on the Labour Benches.
	I was intending to say that not enough planning had been done. However, I was pleased to hear about the forthcoming White Paper, which I think will be helpful.
	Leicestershire county council is a top-performing authority, with an established home assessment and reablement team helping older people to stay independent, living in their own homes for longer and reducing the numbers going into residential care. I speak for the county when I say that it takes great pride in that. It also has a specialist dementia team to help keep people independent with the use of various forms of assisted technology. Leicestershire county council has achieved that despite its low Government grant. As a county, we are right at the bottom of the pile.
	Despite various reviews during the tenure of the Labour Government, Leicestershire's funding is right at the bottom. We come back to the shire county versus inner city arguments. There are many different formulae but we do not get a lot of money. The grant covers only 28 per cent. of our social care budget. Nationally, there is a £6 billion shortage in social care, so it is regrettable that in general the Government have offloaded a lot of financial responsibilities to counties. No doubt, that is part of the reason why there are pressures in Nottinghamshire. I shall not go down the route of discussing the policy of privatising some of the homes there, mentioned by the hon. Member for Broxtowe. Not all privatisation is bad. Sometimes we can achieve efficiencies. In the past, we have seen private organisations develop ideas that may not have come about in the public sector.

Nick Palmer: On a point of information, Nottinghamshire accepts that it has done well from the local government settlement. The council wants to freeze council tax, which is a political issue. Incidentally, I am a doctor of mathematics so the hon. Gentleman should not ask me to operate on him.

David Tredinnick: In that case, I am not sure whether I insulted the hon. Gentleman or paid him a compliment.
	The hon. Gentleman spoke about his county. My recollection is that Nottinghamshire was not always under Conservative control, although I may be wrong. Perhaps the incoming Conservative administration is trying to put right the complete shambles that existed previously. I shall give way to him if he wants to comment on that, but he seems happy to retain his seat. I am not surprised-

Nick Palmer: rose-

David Tredinnick: I give way to the hon. Gentleman.

Nick Palmer: On the contrary, Nottinghamshire is, I believe, the only county in Britain where not only people at severe risk have personal care support, but also people at moderate risk. I may be wrong, but the council is certainly one of the very few, because of the good record of the Labour administration.

David Tredinnick: We had better not go down that route but I remember that in neighbouring Derbyshire the Labour administration was unable to provide enough police cars, and all the muddle that-

Mr. Deputy Speaker: Order. I think the hon. Gentleman would do well to stick to dementia for the time being.

David Tredinnick: Perhaps amnesia got to me in that case, Mr. Deputy Speaker.
	I approve of the policy of free personal care for the critical band, but where will the money come from? It has to be provided by local authorities so it is just another addition. I am happy to stand corrected, but-

Phil Hope: The hon. Gentleman said he would stand corrected, so I want to correct him. The Personal Care at Home Bill is costed at £670 million; £420 million of that will come from the Government and from NHS budgets.

David Tredinnick: I thought the Minister might have come up with a different figure, which is the difference the measure will not provide. That still has to be paid by local authorities.

Phil Hope: I am happy to give the hon. Gentleman that figure, too. The sums are not that difficult. It does not take a doctor of mathematics to do them: £670 million minus £420 million gives £250 million. Local authorities can find that sum through efficiency savings in their delivery of care services for people in the most need, not least by reducing the numbers who have to go into residential care, because they will be supporting people living in their own homes, which is where they want to be.

David Tredinnick: Although I applaud the fact that the Government have made money available, the serious point is that there is a shortfall nevertheless. A feature of the Labour Government is that they have tended to offload central Government costs to local authorities, which has caused problems for those authorities.
	Other Members mentioned the lack of memory clinics-a broken pledge. I am glad to hear that action will be taken on memory clinics. My hon. Friend the Member for Gainsborough (Mr. Leigh), the Chairman of the Public Accounts Committee, referred to some of the issues raised by officials his Committee had interrogated. He might have added that the National Audit Office has said that
	"vast amounts of money have been wasted and there were doubts over whether funding would be found to improve services."
	Conservative-controlled Leicestershire county council has invested local tax payer's money to provide services to improve social care, which has not all been matched by central Government, which is regrettable. The Leicestershire budget, raised through council tax, contributes 82 per cent. of the total cost of adult social care, even before implementation of the measures in the Personal Care at Home Bill.

Phil Hope: I may be mistaken and the hon. Gentleman may be able to correct me, but I understand that Leicestershire announced it would be making one in 10 of its work force redundant. Does he really think that will help people with care needs?

David Tredinnick: We come back to the argument about delivery of service-who does it and whether it is necessary. We have heard that in Nottinghamshire some of the services are to be outsourced. I had better not go down the route of discussing the numbers in employment in Leicestershire, as I have not been briefed in this speech to make those remarks, but I take on board what the hon. Gentleman said. Leicestershire county council has provided services for older people with mental issues. Five workshops have been set up recently for carers and users.
	I can confirm what other hon. Members have said about the money from the national dementia strategy that was sent to primary care trusts. It is certainly the case in Leicestershire that, because that money was not ring-fenced, it has been spent on other things. PCTs were told that the money for the strategy was not included in their baseline figure-to use the correct terminology-and that is regrettable.
	I think that the hon. Member for Leeds, North-West mentioned statistics and the lack of information. These are critical issues. Solutions have been proposed in the Personal Care at Home Bill, and we have heard about plans for improvements for carers, but we have not heard a lot about what can be done to extend the period in a person's life before dementia gets a grip, when they are not forgetful. There are certain measures that could be taken-they are not necessarily seen as mainstream medicine-and I want to focus on three of them.
	The first, which has not been mentioned, is the lack of water. There is a serious problem with getting elderly people to drink enough water. I have raised this matter in the House before, over the years- [ Interruption. ] I am very pleased to see that the Minister has grasped the jug and is pouring himself yet another glass of water. I did not know that I had such powers of persuasion, or that I could get such an instant response from a Minister. The fact is that many elderly people do not drink enough water, although they might drink other things. This creates problems for the body. Simple strategies were applied in studies carried out in India, and it was found that people's susceptibility to illness diminished in direct correlation to the amount of water they consumed.
	The second factor is diet, and particularly the importance of antioxidants and eating fresh fruit. Some foods are specifically effective in treating these problems, one of which is blueberries. I have been making this case for years, not only for blueberries. I can see the hon. Member for Bassetlaw (John Mann) smiling, but this is true. Studies have shown that some fruits are effective in this regard. We do not have enough information, however, and I want to appeal for more information on diet and on certain foods.
	Thirdly, we should also look at some of the herbs that are effective in treating this problem. I am indebted to the Alzheimer's Society for providing me with a briefing on this subject. Many people have benefited not only from using antioxidants and improving their general nutrition but from using herbs prescribed by professional herbalists. There is a problem, however, because the Minister's Department has still not produced its proposals for the regulation of herbal medicine and acupuncture. They have been sitting in the Department for far too long, and it would be helpful if he could give me a date when they are to be published. It would be a great tragedy if they were not published before, shall we say, early May, or even April. The Minister and his Department would really be funking it if they left this for the incoming Government. They should at least tell us what they think, and come up with some kind of policy statement.
	I shall not go into details about the various plants used in herbal medicine. Related to that, however, is Chinese acupuncture, which has also been found to be very effective in this regard. I am reflecting the views of the Alzheimer's Society on this. Whatever I happen to believe, the society believes that there is evidence of the effectiveness of acupuncture. My own knowledge of the subject suggests that it is perfectly possible to achieve results by adjusting meridians.
	Studies have been carried out in Japan on the effectiveness of certain herbs. A product known as kanpo-a mixture of a Chinese herb called choto-san with other substances, including about 11 medicinal plants-has been the subject of investigation. A research study found an improvement in patients with vascular dementia who took that particular combination of herbs over 12 weeks, and decided that further research on the preparation seemed warranted. I should like to make a secondary point on the general regulation of herbs. The regulation process is considering individual herbs rather than the combinations, yet many doctors prescribe a combination of herbs. The Minister should take that into consideration.
	In addition to the range of herbal medicines and products available, aromatherapy has also been helpful in treating patients using massage techniques and certain oils. Again, this should be looked at with great care. Other methods include music therapy: playing certain kinds of music can be helpful for people with this condition.
	I appeal to the Minister to have an open mind on this. He should think about these alternatives, because they are effective, and they are supported by the Alzheimer's Society. I also look forward to his announcing the date for the publication of the proposals for the regulation of acupuncture and herbal medicine, when he winds up the debate.

John Mann: We have heard the policy of the Opposition Front Bench. The hon. Member for Bosworth (David Tredinnick) used the analogy of pudding in relation to certain speeches. The Opposition's policy seems a bit like a jelly: it can take any shape, it can be colourless, and it can be moulded in any way they want. We can never be quite sure what is there. Having heard their attempts at policy, I think it would be helpful if they were to inform the House about what action they would take.
	It is appropriate to judge political decisions on changes to systems and laws, and on priorities relating to the allocation of resources, according to experience and to what people actually do. I cite as my example the county council of Nottinghamshire. Since June, it has been Conservative-run. Not only that, but three of the county councillors wish to become Members of this House at the next election. Nottinghamshire county council therefore represents a microcosm of what Conservative policy on dementia care would be, because we can see what is happening in that county and my own constituency now, before the election.
	The Conservative administration in Nottinghamshire, led by the appropriately named Councillor Cutts and backed by the non-executive cabinet members-all of whom, coincidentally, happen to be prospective parliamentary candidates for the Conservative party-have put forward policies on dementia care, and those policies involve cuts. They wish to privatise residential care. In my area, that involves James Hince Court, a specialist residential dementia care centre in Carlton in Lindrick. It is an excellent centre. It could do with a little more refurbishment, but the quality of care, the professionalism of the staff and the responsiveness to the families are all superb. It has been externally validated as being superb, and my observation and that of the families involved is that it is superb.
	A second example is Westwood. It is a very new facility in my constituency, which deals not exclusively but partially with dementia care. The Tory administration wishes to sell it off to the private sector. A third example is St. Michael's View. I was there last Friday at a meeting of residents-some suffering from the early stages of dementia and some the later stages-and they and their families are unanimous that that excellent facility should remain in the public sector. Why do they oppose the plans of that Tory administration-those would-be sitters on Conservative Benches? The reason is simple: they have experienced the private sector. Most of them moved from the private sector into the public sector. Strangely, private sector care homes have a lot of vacancies; one in my constituency has 31 vacancies. However, there are waiting lists, including of people I know, to go into the three excellent public sector centres, as there are for the other ones in Nottinghamshire. Having sampled, tried, felt, known and paid the private sector, people prefer to go into the public sector.
	The second reason why people prefer public sector homes to private sector ones is that the private sector does not provide a day care facility, where people come in, have a cup of tea and use the expert provision of the staff, but do not stay overnight or pay anything significant towards the overheads. For the private sector, that does not pay. Some of our memory clinics, as they are called, are in public sector residential care centres, where properly trained, expert staff also provide specialist dementia care in a day care facility. That is why families like those centres and are adamantly against Tory privatisations, or, if they cannot be privatised, closures-that will undoubtedly follow from their spending plans.
	What is the response to a major public campaign led by families against such absurd privatisations and day care cuts? Those Tories-would-be Tory MPs and others-propose in their budgets to increase significantly, by about 60 or 70 per cent., the cost of going to day care. They want to cut meals on wheels in the same way-by increasing prices. As has been outlined, they want to cut many other services relevant to dementia care, such as 20 specialist occupational therapist posts. Those are vital jobs that support the elderly and those with dementia. That is the Tories in action. That is what we will see should there be a Tory Administration nationally.
	What is the Tories' response to the public outrage? They say that they will suspend the privatisation for one year. Is it possible that that extends over the election period so that they can claim that they have listened and that it might not happen? The reality is rather different. If we read the financial pages, we see that those in the private sector, including Care UK and others, are having difficulties, and many of them are overleveraged and in big debt-some of them are featured on the front pages. They cannot make lots of profit out of dementia care. The big companies that own loads of care centres across the country cannot make them pay at the moment. I dissociate myself from any consensus that such private centres are as good in quality as public ones, because in my area and Nottinghamshire, the facts-the external ratings-prove nothing of the kind.
	The state of some private centres is a scandal. Let me give an example. Abbeymoor was the nearest one to my office. About a year ago, the staff, who were badly paid and trained by comparison with the public sector, with a higher labour turnover, but who were nevertheless decent, hard-working people wanting to learn a profession and serve the community, elderly residents and those suffering from dementia, turned up for work to find the doors locked. The private owner had decided to close it down, shunt the old folk out, get rid of the staff and not even pay them the holiday pay and wages that they were owed. Thankfully, we have just won a case at an industrial tribunal, which will get the staff the money that is owed. That is not the first tribunal I have had to fight in relation to private sector care homes in Nottinghamshire, but the third-and I have not been an MP that long. Three different care homes have not paid their staff properly. I have been in some of those, and have heard what the families say-not just those who have been lucky enough to get into the council ones, but those who want to.
	Many of the private care homes are a disgrace. Let me tell the House what was happening in Abbeymoor. The staff were having to go out and pay for the food themselves, because the owner was not providing sufficient money. That is a scandal. My only criticism of Government policy is that they should have a stronger inspectorate for private sector care homes, because further scandals will be unveiled. I have heard of a recent inspection of a private home in my area that has a large number of elderly people, some with dementia. The staff were there in the daytime, when the families turned up, but seemed to be missing overnight. They were not there, as though not employed by the big, top, rich company that runs a large number of care homes in the area. In another private home, I am told they stick the residents in bed at 6.30 pm-that is a good quality of life! The hon. Member for East Devon (Mr. Swire) points. Let me point the finger at the people who want to be Tory MPs who are making those decisions.
	I have given the view of the families, but let me give the public view. I sampled that a week ago, when I rang 5,500 of my constituents on an official opinion poll, under market rules to ensure that it was not biased. It gave them a choice: did they agree with the privatisation of care homes? Ninety-eight per cent. were against such privatisation. That is what the Conservative party will bring if it ever gets into power. It dares to suggest that it stands for those with dementia, yet fails to condemn the Tory county council in Nottinghamshire and its disgraceful attack on elderly people, that vulnerable part of society, and their families. That is an insult to our intelligence. My community in Nottinghamshire is fighting back to put the Tories where they should be, and to beat them on those decisions.

Hugo Swire: Last year, Mr. Paul Cann, the director of policy and external relations for Help the Aged, described dementia as
	"fast becoming the hidden epidemic of the 21st century".
	The more debates that we have in this place on the matter, either in Government time, or, as in the case of this afternoon, in Opposition time, the better. The subject needs to be aired and taken extremely seriously and should, on the whole, be non-partisan and non-political, difficult though that is to believe at times.
	One does not need the mathematical skills that I attribute to the hon. Member for Broxtowe (Dr. Palmer) to work out that, looking at isolated demographics, the problem is set to grow rather than recede. In my constituency, 29.5 per cent. of the population is retired, against a national average for the rest of England of 17.3 per cent. In my constituency, I have the retirement destinations, as they are called, of Budleigh Salterton, Sidmouth, Exmouth and so on, so the pressures on local services are huge and set to worsen.
	The Government's national dementia strategy, which is a year old, is, of course, a good thing. I welcome it, although it is belated. It contains important elements that need to be expanded. In the limited time available to me, I shall try not to go over ground covered in this comprehensive debate, but I say, again, that early diagnosis is crucial in the treatment of dementia. The more these memory centres-or clinics, as some hon. Members have erroneously called them-can be rolled out across the country, so much the better. The savings that an early diagnosis can make, in terms of both human suffering and the economy, are huge and should not be underestimated. We have, again, touched on better training for GPs. Some GPs are crying out to be retrained or trained in spotting the early signs of dementia, and they should be assisted in that without delay.
	I wish briefly to discuss research into dementia. The hon. Member for Broxtowe said that we are in a global research environment and to an extent he is right, but it is worth pausing for a moment to remember the following:
	"National Institute for Health Research investment in dementia research amounted in 2007-08 to £22.2 million. The Medical Research Council (MRC) spent £10.2 million on dementia research in the same year. This total expenditure of £32.4 million amounts to some 2.5 per cent. of the combined departmental research and development and MRC expenditure for the year."-[ Official Report, 5 February 2009; Vol. 487, c. 1502W.]
	Those are significant figures, but they pale into insignificance when one considers the sums that are rightly spent on research into cancer and other diseases. Although we are part of the global research family, we need to examine that. I hope that the Minister will not accuse me of ignorance in quoting those figures, because they are figures that he gave me in answer to a written parliamentary question.
	I welcome the appointment of a dementia tsar. The Government's record in appointing tsars over the years has been about as successful as the Russians', and I hope that those tsars will not end up in the equivalent of Ekaterinburg. The appointment of Professor Alistair Burns is welcome, and I hope that he can co-ordinate the many different approaches to the treatment of dementia. My hon. Friend the Member for Tiverton and Honiton (Angela Browning), who has had to absent herself this afternoon, made an extremely good point when she said that every primary care trust should have a dementia champion who can also help to co-ordinate things on the ground.
	I wish to discuss a subject that we have not spent enough time on: objective 7 of the Government's national dementia strategy, which is on "Implementing the Carers' Strategy". It states:
	"Family carers are the most important resource available for people with dementia. Active work is needed to ensure that the provisions of the Carers' Strategy are available for carers of people with dementia. Carers have a right to an assessment of their needs and can be supported through an agreed plan to support the important role they play in the care of the person with dementia. This will include good-quality, personalised breaks. Action should also be taken to strengthen support for children who are in caring roles, ensuring that their particular needs as children are protected."
	The hon. Member for Bridgend (Mrs. Moon), who is not in her place, talked about the spectrum of dementia. The hon. Member for Broxtowe, in a personalised contribution, talked about the good humour that the sufferer often has. What unites the carers is that they are often the ones who suffer most in all this. An estimated 600,000 people in the UK are acting as the primary carers for people with dementia. Two thirds of people with dementia live in their own home and one third live in a care home, thus the majority of people with dementia are probably being cared for either by professional carers or by members of their own family. It is estimated that the saving to the taxpayer is about £57 billion a year, but with that often comes a cost to the carers. Evidence has been found of carers dipping into their savings that they have put aside to help care for the person with dementia, which reduces what they have to look after themselves in later life.
	It has also been found that 65 per cent. of people with a caring responsibility do not identify themselves as a carer in the first year of care-such people are often referred to as the "hidden carers". It is not just that category of people who are hidden carers. An awful lot of people who still believe in the family and look after their partner-their husband or wife-would never dream of regarding themselves as carers. Such people regard themselves as being a husband and wife and it being part of their duty to look after their lifetime partner. They also deserve our support.
	Interestingly, and sadly, about one in five of the nation's 4.4 million careers of working age have to give up their employment in order to care. Many carers of people with dementia are older people who have physical frailty and health conditions of their own. At a dementia seminar in Exmouth earlier this year, I met one lady-she was not complaining and did not necessarily want more help from the state-who has looked after her husband for 20 or 30 years, which is a life sentence. She does not regret it in any way, but she is becoming increasingly frail and in need of support. Such people are often the unsung heroes and heroines of this tragic tale.
	Nearly 45 per cent. of working age carers say that they would like to work, but 38 per cent. say that they cannot work unless the right care services are in place for them. Between 40 and 50 per cent. of working carers say that a lack of flexibility and sensitivity in the delivery of services hampers them in obtaining support.
	I touched on the question of child carers earlier, and it is incumbent on us to take that issue seriously. Children who end up as carers often get overlooked, but their own education and passage into adulthood gets compromised in some way. I have also alluded to Admiral nurses, who are fantastic. We need more of them, as they do a magnificent job, but I shall not dwell on that point.
	I wish also to discuss respite care, which has been mentioned again today. Carers of people with dementia, probably more than any other category, need respite, if only to take some time off to go for a walk with the dog, to have their nails done or to go to the hairdresser. They just need to have a little bit of the life that they once had back, as that will, in turn, make them better carers. However, too often, we have seen day centres up and down the country close. The other day, I went round Stowford lodge in Sidmouth, in my constituency, which is used as a day care centre by people with dementia. Some of its bedrooms were being used as storerooms, but that is criminal. Surely this country should have a system in place whereby any beds in a purpose-built care centre should be available for overnight respite. It is incumbent on all political parties-this is a challenge for not only the current Government, but any future Government-to find a way to finance this properly in order to care for these extraordinarily vulnerable people.
	Charges hit people with dementia hardest for four reasons: care is more expensive in care homes and two thirds of people in them have dementia; more dementia care comes from social services, and that is means-tested; people can need care for extended periods; and end-of-life care for dementia often takes place in a care home, rather than in a hospice or hospital. It is worth making the point that if somebody with cancer needs chemotherapy or surgery, or if someone with heart disease needs a heart bypass, that is provided free on the NHS, but if someone has a disease of the brain that causes dementia, their care is often provided by the local authority and is means-tested.
	I do not want to revisit the case of my constituent, Mr. Mejor, on which the Minister accused me of being ignorant.

Phil Hope: The hon. Gentleman has to be very clear. I am interested to hear what he will say about this, as he intervened earlier on other colleagues. It is quite clear that, if a couple are in their own home and one of them goes into residential care, the home is disregarded when it comes to assessing the means of that couple, because somebody is still living in the home. It is only when the second person goes into residential care -if they both have that misfortune-that the home will be assessed. A deferred payment scheme should operate, and I hope that such a scheme operates in his area, which would mean that that home would not have to be sold until neither of the couple remain alive. Those are two different points, one of which was made by my right hon. Friend the Secretary of State in response to an earlier intervention. I hope that the hon. Gentleman will accept that knowing that fact-in other words, not being ignorant of it-might help him to represent his constituent's case.

Hugo Swire: I am most grateful to the Minister. My constituent, and everybody in East Devon, will be most interested to hear the Minister virtually make a commitment that there is no way that the Mejors can lose their home in this sorry episode. That is a magnificent thing, if that is what he is announcing this afternoon. The reality is that the case will be heard again at the beginning of February. I hope that Mr. Mejor will receive a continuing needs assessment, because he needs it, as far as I am concerned. He has at home an elderly wife and a daughter who has had to sell her home in order to care for her elderly parents. However, the truth is that if his case fails, it will be up to local social services to assess his needs, at which point charges towards the £800-a-week place in the Linksway nursing home can be re-examined and reassessed. That is, I think, the threat.
	The Government are leaving this country in a sorry economic state, but I think, more than anything else, people want honesty now from their politicians. Surely, in all honesty, we need to acknowledge the problems that we have with the demographics, with the rise in people's ages and with the problems that those changes present with mental disease. Surely, at the end of the day, whatever the cost, it is our duty as legislators to protect those who are most vulnerable in society-those who are coming to the end of their lives and those who have, so often, selflessly cared for them.

Jeremy Wright: I begin by joining the tributes that have been paid to Neil Hunt, the departing chief executive of the Alzheimer's Society. He has done a great deal, as most people involved in this issue know, to drive the subject up the political agenda to where it rightly deserves to be.
	I also regret the absence from this debate of David Taylor. I know that he would have been here to contribute, as he always did on these issues. He was a well-respected and assiduous member of the all-party group that I chair, and he will be missed in this debate, as he will be in many others.
	The numbers that we discuss whenever we talk about dementia are staggering. Hundreds of thousands are affected now, millions will be affected in the future and billions are being spent on the treatment and management of dementia at the moment; it is possible to become immune to those numbers and to forget the scale of the challenge that we face. However, some numbers still have the capacity to shock. The review of anti-psychotic medication undertaken by Professor Sube Banerjee recently reported to the Government and is, I think, one document that contains such figures. To know, as we stated in the all-party group's report on this subject some time back, that there is a substantial degree of over-prescription of anti-psychotics among people with dementia is one thing, but to hear from Professor Banerjee that he thinks that some 140,000 people are wrongly on those drugs-the deleterious effects of which have already been discussed in the debate-and that, worse yet, an additional 1,800 deaths a year result from that excessive prescription, as do 1,600 or so strokes and the like, truly, in my view, puts this scandal into its proper context and underlines the need for action.
	I, like others, welcome the appointment of a national clinical director in dementia. That is a positive move forward, and I hope that the Minister will confirm that one of that clinical director's first priorities in office will be to address this serious issue. One suggestion from Professor Banerjee to deal with the trouble caused by the over-prescription of anti-psychotics is to address the fundamental issue of training. The Minister knows, not least from the other report produced by my all-party group, how strongly I feel about that subject and how central it is to the issues of dementia care in general. I shall not dwell on it now-I do not have time-but I simply repeat a request that I have made to him in the past, which is that he should keep it very much at the forefront of his mind, that we should set up substantive mechanisms to ensure that qualifications are available for those in the caring profession, that career paths should be set out in specialist dementia care and that everybody who has contact with those with dementia, which includes a large number of people across a variety of fields, has some understanding of the condition that is being dealt with.
	I concede that training features as part of the national dementia strategy. I repeat my welcome for the strategy, as it is a very positive move forward and contains a great deal that needs to be done. The Secretary of State was right to say that we should not expect everything to be done by now, less than a year into a five-year strategy. I accept that it will take time to complete, and the Government have been right to say repeatedly that dementia is a priority for them. It is a national and a Government priority, but in this debate we should ask what that means. For example, does that mean that more money will be made available for researching a condition that has become a Government priority? As others have said, it is not apparent that that is what it means. The level of research has not increased at all, let alone dramatically. Greater priority should be given to dementia research; if it is not, we will not be able to address that widespread problem in a fundamental way or start to reduce the costs to the Exchequer that it incurs.
	Does a Government priority on dementia mean that the Government will take action more quickly, or that they will radically change the operation of the relevant systems in the fields of health and social care? Does it mean that the Government will spend substantial amounts of new money specifically on this priority? I regret to say that I do not think that the evidence suggests that making dementia a Government priority means any of those three things, as I shall briefly explain.
	First, have the Government been quick to set our their response to the challenge? Although I welcome the national dementia strategy, it was promised repeatedly-from August 2007 right up to its publication in February 2009. An implementation plan with any significant detail came only later still. I have said that the review of anti-psychotic drugs is welcome and important, but it was originally promised a long time before the strategy. The review was finally published on 12 November of last year, some seven months after the strategy was published and some two years after it was originally promised. Those delays do not have the hallmark of action that is a Government priority.
	Secondly, has making dementia a Government priority initiated radical change in how this country's health and social services are run? The context is important here. This is a Government who set considerable store by central control. They set targets that they consider important, and which those delivering services must meet.
	Earlier, the Secretary of State said that the Opposition cannot have it both ways, but neither can he. If the Government believe that that is how the health service and social services should operate-with a great degree of central control exerted by means of the levers attributed to Whitehall-then they cannot simultaneously refuse to pull those levers and make something happen, saying that doing so is not their department.
	Reference has been made to the NHS operating framework, the mechanism by which the Government communicate their priorities for the NHS. Due to the delays that I have described in bringing the dementia strategy forward in the first place, the Government missed the boat entirely in the operating frameworks for 2008-09 and 2009-10.
	As we have discussed, those frameworks set out three tiers of priorities for the NHS-the things that all PCTs must do, national priorities for local delivery and priorities to be set locally. Dementia is not mentioned specifically or substantively in any of those tiers. Worse still, the 2009-10 framework published in December 2008-before the strategy was published, but after the substantive work that there must have been to enable the Government to know what they were seeking to achieve-stated that there would be no new national targets in the NHS until the next spending review. We are, of course, still waiting for that review. Even in the 2010-11 version of the framework that was published in 2009, there is only a brief reference to dementia, and that was about the improved outcomes and efficiencies to be gained by early diagnosis of the condition.
	It is not true either that GPs, as part of the NHS, are being asked to do a great deal of specific work on dementia. The existing qualities and outcomes framework has only two criteria relating to dementia, and they are about maintaining a register and having 15-monthly reviews. I accept that those criteria are important, but they are not as fundamental as perhaps they should be. That is a good Government priority, and it is a substantial issue that should be addressed, but there is not much evidence of their doing so in the control mechanisms that they have put in place for the NHS. There is no evidence of a speedy response or of significant changes in the systems that deliver care.
	What about the money? Have the Government given substantial extra resources to those who deliver care and said that those resources must be spent on the new priority of dementia care? Again, the answer is no. There is no ring-fencing, and there is no reporting requirement for PCTs to tell the Government whether, in fact, they have spent the £150 million allocated over two years across the country on dementia care. We must ask, in all common sense, how confident we can be that cash-strapped primary care trusts facing an array of different Government targets are necessarily going to spend all that money on dementia care. We have to wait for the Government's audit to find out, but I am not immensely optimistic.
	If the Government priority does not mean urgent action, if it does not mean substantially changing the systems, and if it does not mean substantially increasing the resources allocated specifically to the problem, what on earth does it mean? The danger is that the Government have set up tremendous expectations by rightly isolating dementia as a huge challenge that we must confront. If a Government priority is nothing more than a soundbite, and if a national dementia strategy is nothing more than a title, we run the risk of not only disappointing the hundreds of thousands of people with dementia now, their carers and the people who love them, but disappointing millions more in future and failing to face up to the challenge that we must face up to in the next few years. If the Government, who are running out of time, are unwilling to take on the challenge and take the necessary action, I fear that it will fall to the next Government to do so.

Shailesh Vara: It is a pleasure and privilege to follow my hon. Friend the Member for Rugby and Kenilworth (Jeremy Wright).
	Let us be clear about one thing. When we talk about dementia, we are effectively talking about people who have given the best years of their life to contribute to society and to make sure that the rest of us are in a better position than they were when they were living active lives. It is only right and proper that we, in turn, should look after them and treat them with the dignity and respect that they deserve. Sadly, however, that is not always the case. In fact, analysis shows that Britain is in the bottom third of European countries for diagnosis and treatment of dementia-below almost all northern and western European nations.
	There are a number of reasons for that, including the stigma attached to dementia. It is not right that in the 21st century people should still be afraid to admit that they have dementia or that they have relatives with dementia. I was pleased that the Secretary of State said that there is going to be a publicity campaign to highlight the issue of dementia, and to reduce the stigma attached to it. I very much hope that it will highlight the early warning signs-for example, confusion, forgetfulness, problems with speech and so on. If someone thinks that they have those symptoms, they might take advice, and go and see a doctor.
	Early diagnosis is a good way of dealing with the problem, and we have heard a great deal about the need for specialist doctors and other medical professionals to provide that. At present, as we have heard, one in three people receive formal diagnosis at any time in their illness. That statistic has simply got to change. We need to ensure that far more people experiencing the onset of dementia know that that is the case, to allow them to plan them for the future, when the illness will undoubtedly become worse. It means that families can become involved, especially in making plans for people who wish to receive care at home. It also enables people to talk to medical experts and social care services.
	One of the crucial themes of the debate has been the repeated mention of support for families. May I add my appreciation of the superb work done by hundreds of thousands of family members throughout the country in supporting their loved ones who are suffering? In many cases the care is given at home, which eases the pressure on the social care services-something that is not often commented on. It also ensures that those who are suffering are able to maintain a sense of independence and dignity.
	We must recognise that many family members themselves have other problems and illnesses, a point mentioned by the hon. Member for Broxtowe (Dr. Palmer). As well as the pressure of looking after somebody who is suffering, they have to endure the personal pain of seeing a loved one decline. Relatively older people are looking after even older people who are suffering. In many instances, pensioners are looking after their elderly relatives and parents.
	Given the importance of the subject, it is worth while considering the Government's record. The Government gave it priority only after receiving a couple of critical reports. In 2007 the King's Fund reported that the scale of dementia in the UK was considerable. The National Audit Office report in July 2007 highlighted the poor diagnosis, poor quality of care, and the disjointed approach taken by health and social care services.
	It was only after these reports that the Department of Health could bring itself to admit that dementia should be a priority. That was in 2007, when the Government had been in place and running the administration for 10 years. At that time Age Concern summed up the situation by stating:
	"For far too long, vulnerable older people with dementia and their families have been treated as second-class citizens".
	It took a further two years for the Government to produce their national dementia strategy-10 years to recognise that the matter deserved priority, and a further two years to produce a strategy.
	What is the position a year on? The report issued less than two weeks ago by the National Audit Office was anything but complimentary. It spoke of local leadership for improving dementia care still not being in place. It said that most primary care trusts and local authorities were still awaiting guidance from the Department of Health before beginning their baseline reviews of dementia needs and services. The Alzheimer's Society has commented that a third of GPs still lack confidence in diagnosing dementia, and that nurses have so far received no information on the Government's strategy. Indeed, dementia is not included in the nurses' core subjects when they are training. Yet the Labour party, in its 1997 manifesto, spoke of ensuring that the views of pensioners would be heard, and said:
	"Everyone is entitled to dignity in retirement."
	I conclude by adding my praise of the Alzheimer's Society, Age Concern, Help the Aged and the many other similar charities and organisations that continue to do such sterling work.

Anne Milton: Some 700,000 people have been diagnosed with dementia, although there may be many more undiagnosed. That figure will rise to 1.4 million in the next 30 years, and includes one in 14 people over the age of 65, rising to one in six over the age of 80, and predicted to rise further. One way or another, dementia touches the lives of half the population, with close friends or family suffering the effects.
	We have heard a great deal this afternoon about the importance of early diagnosis, early treatment and intervention, and proper and effective support for the person with dementia and for those caring for people with dementia. Rehabilitation has not been mentioned much in the debate, but it is extremely important for those with dementia to be able to carry on and be as active as they can. All these aspects are vital, but what is needed is more than a strategy, although that would be welcome. Effective implementation is needed, which I do not believe the Government truly understand.
	I was a bit disappointed that the Secretary of State took the debate at such an early stage into party politics- [ Interruption. ] No, it was he who mentioned it first. He confused priorities with targets, but we do not need targets; we need outcomes. We need implementation that will make a real difference to people's lives-implementation that improves the outcomes for people suffering from dementia.
	I was also surprised and very disappointed, actually, to hear the truly scurrilous remarks and unfounded allegations about an influence on our policy making. There is no such influence, and no conflict or possibility of conflict; everything that we do is open and fully disclosed. The hon. Member for Bassetlaw (John Mann) is no longer in his seat, but before he throws stones across the House, he should more appropriately ask his own Government about the money that independent sector treatment centres received for not doing operations.
	I pay tribute to my hon. Friend the Member for Rugby and Kenilworth (Jeremy Wright), who has made not only a valuable contribution today but a significant impact in raising awareness of dementia through the all-party group on dementia and his interventions in many other debates. The hon. Member for Broxtowe (Dr. Palmer) shared his very personal experiences, and his concluding remarks about a continuous spectrum of care and treatment were apt and particularly pertinent.
	My hon. Friend the Member for East Devon (Mr. Swire) mentioned, in particular, the needs of carers and the hidden carers, including our child carers, who are often forgotten in the debate. My hon. Friend the Member for North-West Cambridgeshire (Mr. Vara), whose contribution was sadly cut so short, rightly spoke of the need to treat people with dignity and respect, and I pay tribute also to the hon. Member for Bridgend (Mrs. Moon), who made a number of insightful points. My hon. Friend the Member for Bosworth (David Tredinnick) raised a number of issues that are important to many of his constituents, not least his concerns about the funding shortfall for his local authority.
	The National Audit Office report said that £8.2 billion has been spent inefficiently on dementia care every year. It found that although some steps had been taken and some improvements made, much more needed to be done to improve care and save literally millions of pounds. It found also that more than half of GPs surveyed had not had adequate training, and that one third remain unconfident about diagnosing dementia. Only one in five said that a senior clinician had taken the lead for improving dementia services in their hospital; and only 15 per cent. of psychiatrists said that their primary care trust had invested extra funds in the service.
	Nurses, the report continued, received no information on the strategy; joined-up health and social care working is patchy; people who are admitted to hospital increasingly have longer stays and end up in residential care prematurely; only two strategic health authorities are actively working with the care home sector; there has been no improvement in GP knowledge and awareness in the past five years; dementia is not included in the core requirements for nursing degrees; it is not a priority in the 2010-11 operating framework; and it is not part of a national set of priorities against which the performance of organisations has been measured.
	The fact that literally billions of pounds is spent inefficiently is truly appalling, and never has there been a greater need to ensure that all money is spent effectively and efficiently, and that above all else it is directed to and centred on the people who need the care. In the meantime, as my hon. Friend the Member for Leeds, North-West (Greg Mulholland) pointed out-

Rob Marris: Friend?

Anne Milton: The hon. Member, perhaps I should have said. The savings made from families, friends and charities, who deliver probably the majority of care, are huge, and I pay tribute to those charities and carers-the unsung heroes in our communities-without whom the care of people with dementia would surely suffer.
	We are still not clear about where all the funding will come from. In their briefing for this debate, Age Concern and Help the Aged state that the Government's Green Paper is
	"worryingly vague...leaving many frail and disabled people anxious about the future of the benefit."
	As for the carers strategy, as my hon. Friend the Member for Eddisbury (Mr. O'Brien) said, £50 million given out for respite care never reached the front line. Despite many good words in the dementia strategy, we still do not know where three quarters of the £1.9 billion is coming from. We in this House need to know, older people and their carers need to know, and the public need to know. The National Audit Office pointed out that even in the costings that we have there are still no comprehensive data on what dementia services will cost. Perhaps the Minister will tell us when the updated impact assessment will be published.
	We have heard a lot about drug treatment and anti-psychotics. More than a decade ago, the Royal College of Physicians warned that too many people in care were spending their final months and years in a state of suspended consciousness, occupying a half world and waiting for death to come. It highlighted the use of the liquid cosh to keep older people with challenging behaviour easy to manage by using high doses of anti-psychotic drugs. That was unacceptable 10 years ago, and it is unacceptable today. There is clearly a need for increased training and awareness of the use of these drugs and, perhaps more appropriately, their misuse.
	Malnutrition has also been mentioned, and we have recently seen the appalling scandals with people literally starving, and tube feeding being used in care homes. In 2007, the  Nursing Times reported that nine in 10 of the 4,000 nurses it polled said that they were forced to take on increasing administrative work. The nurse of the year resigned in anger at the time wasted on NHS bureaucracy, talking about layer upon layer of red tape. Without a doubt, there are training needs, but there is also, never more than now, a need to allow nurses to nurse and look after the people in their care. Nurses and care staff need training, but they also need time to look after people's nutrition.
	Many older people with dementia end up spending much of their time in a combination of care settings-in acute hospitals, and in community hospitals where they still exist-being looked after by a wide variety of nursing staff and care staff, as well as in their own homes. Ferguson wrote:
	"This morning I would ask you to look with me at that no-man's land between Hospital and community. For most people Hospital care is not more than an episode, albeit an important one, in a much longer chain of events and Hospital care must be viewed, not in isolation, but as an integral and closely integrated part of health and social care."
	That was said in 1967, and those words hold good today. We need integrated health and social care delivered as part of a chain of events; no more inappropriate use of anti-psychotic drugs; time for nurses to nurse, freed from the burden of paperwork; proper training of staff at every level; proper education to end stigma; recognition of the need for the right levels of research, and how we deliver that; and a clear and unambiguous focus on outcomes. What defines us as a civil society is how we care for and look after older people in our communities.
	This has, on the whole, been an excellent debate. Although at this time party politics boils to the surface, the solutions lie in a consensus and in having the right policies and strategies that deliver the very best outcomes and the very highest standards of care for some of the most vulnerable people in our society. I urge all Members in all parts of the House to cast aside party politics and support the motion.

Phil Hope: A few months ago, I visited a new memory clinic in south London that is an outstanding example of what our dementia strategy is all about. While I was there, I spoke to a married couple. The wife had been diagnosed with dementia and the husband was looking after her. They told me how they felt relief at finally getting the diagnosis and an explanation for what was happening to them, and said that since then, they had been more active and doing more things together than they had ever done. They were playing a fuller part in their community and seeing more of their family. The picture that they painted was of a couple living well with dementia, not dying of it. They had the knowledge and support that they needed to enjoy a good quality of life-life with a zing-and they were making the most of it.
	Thinking about that couple, I am pleased that Members such as my hon. Friend the Member for Broxtowe (Dr. Palmer) and my hon. Friend the Member for Bridgend (Mrs. Moon) talked eloquently about those living with dementia. They painted a picture not of inexorable decline but of people being able to live well and die well with dementia when the time comes.
	To find the right response to the challenges that exist, including the demographic challenges, we must start with the right attitude. We must open our arms to an ageing society, not wring our hands. We need to be positive about how we can help older people not simply to get by, but to flourish and live full lives in times of both health and illness.
	The title of the Conservative motion, with its reference to "the elderly", sums up how far the Opposition have to go in their thinking. It is a label that conjures up a stereotype of decline and dependency. In contrast, we are optimistic about what older people can do and what we can do for older people. We see an ageing society as a challenge, but also as a massive opportunity. It comes down to four things. First, we need better general support for all older people, so that they can enjoy their lives to the full. Secondly, we need more targeted support, allowing older people to live well and to live longer in their own homes if they become frail or unwell. Thirdly, we need stronger health and care services so that older people are safe and well supported. Fourthly, we need a deeper cultural change across public services and society at large, so that people are viewed as an asset and treated with dignity and respect.
	As a Government, we have made it a priority to provide additional support to every older person. Other Members have not mentioned this, but we must not forget the entitlement to a free national bus pass and free sight tests, or the winter fuel payments to help older people, particularly in the winter that we are experiencing. There is also extra help with pension tax credits. We are banning age discrimination in health and social care and building a society for all ages. We have appointed a new national clinical director not just for dementia but for older people, Professor David Oliver, a leader in older people's health care who knows how public services work. His influence will be critical in enabling us to ensure that all older people get the services that they need as individuals.
	We have debated in the House free personal care for people living at home with the greatest needs. It must be a shared view throughout the House that older people must be supported to live well and live longer in their own homes. Our work on prevention has been hugely successful, and we have seen best practice on matters such as preventing older people from falling over and getting fractures and improving access to services such as affordable foot care. There has been new guidance on intermediate care and new support for services such as audiology and telecare. Research has now proved that if we put a pound into prevention, to provide people with help in their own homes, we save £1.20 in acute care by reducing the number of people going into it.
	Our Personal Care at Home Bill will provide extra help to keep older people with the highest personal care needs in their own homes, and it has been widely accepted. It went through this House without opposition on both Second and Third Reading, and it is now to be debated in the House of Lords. It means that people who have had to run down their savings to be looked after in their own homes can now look forward to having the peace of mind of not worrying about whether they can pay for their care when they are at their highest level of need.
	Today, we have debated the dementia strategy-a national strategy, with an implementation plan, headed by our new national clinical director for dementia, Professor Alistair Burns. Our regional deputy directors oversee the strategy's delivery locally, and guidance for local commissioners has also been published, as our clinical director audits the services that are being delivered, including local memory clinics, memory centres and memory services.

Lindsay Hoyle: I am pleased that my hon. Friend mentions memory clinics or surgeries. He will be pleased to know that the Tory candidate in Chorley is gathering signatures in support of the Labour Government's proposals. What does he think about that?

Phil Hope: I am always pleased when Conservative candidates campaign for Labour policies, but I would tell voters in Chorley to get the real thing and vote Labour, which designed and will deliver the policy in the years to come.
	It is a Government priority to deliver our national dementia strategy. It was interesting that when Conservative Front Benchers were challenged about their criticism of us for not giving it priority, their promise to make it a priority disappeared within almost two minutes of its being announced at the Dispatch Box. They will not make it a target or a vital sign. They will not put it in the national operating framework or mandate it locally; their words are exactly what we expected-pure fluff. They are all spin and no substance-no change there. What did they say on the airbrushed poster about support for the NHS? We have seen some airbrushing today.

Andrew Lansley: The Minister is currently responsible for the dementia strategy; I hope that we will be responsible in future. For now, the question to him is why the operating framework, which was published last month, did not mention the dementia strategy in the national priorities for local delivery. It is not even mentioned in the vital signs. Even it were a matter simply of saying, "We've given the PCTs the money; it is a national priority to do something with it", why did not the Minister get anything into the national priorities for local delivery?

Phil Hope: It is good to see the hon. Gentleman taking part in the debate; we thought he had decided to leave us for a while. Of course, the strategy is in the national operating framework-it was in last year's and it is in this year's. Given that he aspires to be Secretary of State for Health, he should answer a couple of questions. How many meetings has he had with Nurses for Reform, which would like to privatise the NHS? We know that the Leader of the Opposition has held such meetings. Would the hon. Gentleman like to tell us whether he has done so? No, he will not stand up and reply. He has received donations-questions have been asked about that and a conflict of interest today. We have heard Conservative Members claiming that there is no conflict of interest. If that is true- [Interruption.]

Shailesh Vara: On a point of order, Madam Deputy Speaker. When contributions were mentioned earlier in the debate, the Speaker was in the Chair and the Minister was in his place and listening. The Speaker specifically advised that such issues should be referred to the Parliamentary Commissioner for Standards and not brought up on the Floor of the House. Will you kindly advise me on what should be done when a Minister, who heard that, ignores the Speaker's comments in the same debate?

Madam Deputy Speaker: I was aware of the earlier point of order and accusations. For the benefit of Members, I will repeat Mr. Speaker's response because that is probably the most appropriate thing to do.

Stephen O'Brien: The Minister should withdraw his comments.

Madam Deputy Speaker: Order. I shall repeat the ruling that Mr. Speaker made earlier in the debate. He said:
	"I am grateful to the hon. Gentleman for his point of order. I will respond as follows, and I hope this is helpful to the House.
	First, of course, responsibility for the registration of interests rests with individual Members. Secondly-I listened very carefully to what the hon. Gentleman said-if any Member has anxieties or is discontented about the conduct of another Member, the Member who is dissatisfied should complain to the Parliamentary Commissioner for Standards. At this very tense and competitive time, I should hope that Members would not air these matters on the Floor of the House when they are matters not for the Chair, but for the Registrar of Members' Interests and the Parliamentary Commissioner for Standards."
	I repeat that for the benefit of all Members.

Phil Hope: Thank you, Madam Deputy Speaker. Other questions were raised about points of detail. The hon. Member for Rugby and Kenilworth (Jeremy Wright) spoke of the importance of research into dementia. I can assure him that with a £1 billion forecast spend in 2010-11, assuming this Government are returned to spend that cash, I have funded a research network, and we want better bids for research funding for the benefit of research.

Rob Marris: Speaking of the Leader of the Opposition, does my hon. Friend agree that a politician who puts out photographs that have been airbrushed to remove the wrinkles of age shows contempt for older people?

Phil Hope: Airbrushing a face is one thing, but airbrushing policies is another.

Madam Deputy Speaker: Order. Perhaps the Minister would like to respond to the debate rather than that intervention.

Phil Hope: Madam Deputy Speaker, I was talking about dementia research when I was intervened on, but I take your guidance.
	On the use of anti-psychotic drugs, I can confirm to the House that over-prescription of such drugs is unacceptable. The review of those drugs that I commissioned was comprehensive in taking things forward. I can confirm that the national clinical director for dementia will oversee matters, ensuring that every PCT sets targets for reducing the use of those anti-psychotic drugs. We must improve the way we look after people with dementia.
	It is vital that we treat people with dignity and respect. I am delighted to say that we have a social movement of more than 12,000 dignity champions taking forward-from the bottom up, not just from the top down-the needs and values of, and support for, older people. As we move towards a national care and support service, we have a clear choice. On the one hand, we could retreat to the traditional views of care, and the old models and assumptions about the elderly, and to lumping older people into the same old box, not treating them as individuals, offering no alternative but to go into a care home, and making no real effort to keep people independent; or we could choose a different future, in which age is valued and not dismissed-

John Baron: claimed to move the closure (Standing Order No. 36).
	 Question put forthwith, That the Question be now put.
	 Question agreed to.

Question put accordingly (Standing Order No. 31(2)), That the original words stand part of the Question.
	 The House divided: Ayes 162, Noes 275.

Question accordingly negatived.
	 Question put forthwith (Standing Order No. 31(2), That the proposed words be there added.
	 Question agreed to.
	 Main Question, as amended, put and agreed to.
	 Resolved,
	That this House wishes to see the quality of life improve for the 700,000 people in the UK with dementia; pays tribute to their families and carers and all those who campaign and fundraise for dementia charities; welcomes the Dementia Strategy launched in 2009 which contains a programme of work to transform services for those with dementia over five years and is backed by funding of £150 million over two years; notes that the Government will shortly publish the report of the Nutrition Action Plan Delivery Board; rejects the use of tube feeding on any grounds other than clinical need; welcomes the independent clinical review of anti-psychotic drugs which contains recommendations for the reduction in the use of these drugs for people with dementia; further welcomes the appointment of a National Clinical Director for dementia to promote better care and provide leadership for the implementation of the strategy; welcomes the creation of a Ministerial group to develop dementia research; recognises that the enactment of the Personal Care at Home Bill will help some 400,000 people with the highest need; supports the Government's proposals to create the National Care Service, the first national, universal, entitlement-based system for care and support in England; and acknowledges that the Government's Dignity in Care campaign is working to engage local people in a social movement and to put dignity of those in care at the heart of services.

Out-of-Hours Care

Madam Deputy Speaker: I inform the House that Mr. Speaker has selected the amendment in the name of the Prime Minister.
	Before we start the debate, I should remind the House that an inquest is still taking place into the death of Mr. David Gray and the role in that death of Dr. Daniel Ubani. The House's sub judice rule prevents us from debating the matters awaiting decision in the courts. There must, therefore, be no direct reference to that particular case this afternoon. When the inquest is over, there will be opportunities for Members to raise the issue and the lessons learned in the House. May I also advise the House that an eight-minute time limit will be imposed on Back-Bench contributions?

Mark Simmonds: I beg to move,
	That this House supports family doctors as the bedrock of healthcare services in the NHS; recognises the need for high-quality out-of-hours care; believes in simpler, reliable access to urgent care and primary care on a 24 hours a day, seven days a week basis; regrets that the Government's 2004 GP contract has not achieved this and has in many places divorced GPs from the service provided to their patients; is concerned that services are variable and the burden on accident and emergency services has increased as a result; is deeply concerned by failures in the out-of-hours system; calls on the Government to allow GPs to take responsibility for commissioning of both out-of-hours care and urgent care services; and further calls on the Government to publish its report on out-of-hours services which has been submitted to the Department of Health.
	Let me start by thanking you, Madam Deputy Speaker, for that statement. We are all keen to learn the lessons of the inquest and we await the results with interest.
	It is important that the House understands how we have arrived at the current structure of out-of-hours care, which is at best patchy and has been described by the Public Accounts Committee as "shambolic". In 2004, the Government renegotiated the GP contract and effectively allowed 90 per cent. of GPs to opt out of providing out-of-hours care. It has become clear that the Government mismanaged the contract, which passed responsibility for commissioning out-of-hours care to primary care trusts, away from general practitioners. That has undoubtedly undermined patient care and safety in some areas.
	Out-of-hours and urgent care are valuable and vital services. Out-of-hours care alone is used by 9 million people in England every year. Such services provide essential health care between 6.30 pm and 8 am, and at weekends and on bank holidays for people who require medical advice and assistance, but are not so unwell as to require a visit to accident and emergency. The current system in England, which is commissioned by primary care trusts, has led to huge variations, enormous disparities in compliance and significant cost differences. The system is three times more expensive in some areas than in others, but most importantly, there are enormous variations in the quality of patient care. The most obvious and clear difference is that where local GPs are involved in the provision of out-of-hours care, the service is significantly better.
	Hon. Members may think that some of the problems are recent, but there have been failings in the Government's out-of-hours system since 2004. Only 9 per cent. of contracts were in place when the service began. Only 39 per cent. of PCTs ran a competitive tendering process to award contracts and, most concerning of all, failures in out-of-hours services have contributed to otherwise preventable deaths, including that of Penny Campbell in 2005. The House will recall that after that terrible tragedy the Prime Minister said that the NHS must
	"do better in the future,"
	and that round the clock care had to improve, yet there is still no evidence of widespread improvement and in some areas the service is still very poor, as we have recently witnessed.
	Additionally, at the inquest into Miss Campbell's death the coroner found that lack of access to patient notes had contributed to her death. The then Health Minister-now the Secretary of State for Culture, Media and Sport-asked all primary care trusts to review their arrangements for the transfer of information between clinicians, to ensure patient safety and continuity of care. It is my understanding that the review has still not been implemented and that many out-of-hours doctors cannot access patient records. It would be helpful if the Minister could confirm what has happened to the review.
	There is growing concern about the quality of out-of-hours care in many parts of the country, as is demonstrated by the increased number of complaints about the out-of-hours service and the increasing dissatisfaction of patients. The Medical Defence Union recently calculated that there has been a 50 per cent. increase in complaints related to out-of-hours consultations, notified by its GP members.
	However, the Minister may be pleased to hear that I am mildly encouraged by the fact that the groundswell of concern has led to some action. I understand that the Care Quality Commission is undertaking a review of out-of-hours services, focusing on areas where specific cases have been raised. Early evidence from the inquiry suggests that although primary care trusts monitor response times for out-of-hours services, they do not routinely monitor the quality of care provided or delivery against contractual requirements. It is clear that not all PCTs are aware of the level of service being provided, and in many cases contracts are not routinely monitored, reviewed or robustly assessed. Surely, there should be rigorous monitoring everywhere, looking at the quality of clinical decisions, the efficiency of call handling, and the adequacy of staffing and of doctors' training, as well as the all-important patient outcomes.
	In the vast majority of cases, the contracts were built to national frameworks and were not designed to fit existing services, such as minor injury units, nor to meet the specific needs of local populations. For example, in rural Lincolnshire, where my constituency is, the needs are very different from those in central Birmingham, where I was discussing this very issue with local GPs last week.
	Not only does the local quality of out-of-hours service provision vary around the country, the cost varies significantly, too. Of course, it needs to be recognised that the provision of those services is likely to be more costly in rural areas, but there seems to be no correlation between cost and rurality and cost and quality, despite costs per patient varying threefold. In 2007, the Select Committee on Health concluded that if every PCT provided its service at the same cost as the most effective service with similar characteristics, £134 million could be saved, which could then be reinvested elsewhere in front-line patient care.

Alan Beith: The hon. Gentleman recognises that it often costs more to provide those services in rural areas. Does he share my experience? In my area, we have to obtain doctors from a location more than 60 miles away. That is the situation after midnight in north Northumberland and it is simply not acceptable.

Mark Simmonds: I am grateful to the right hon. Gentleman for that intervention. He is absolutely right. There are similar issues in my Lincolnshire constituency. The most recent case relating to his experience that has come to light in the media was in Suffolk, where after midnight a population of 600,000 is covered by only two GPs. That is not acceptable-it is not the service the public in England expect.

Andrew Murrison: Does my hon. Friend share my concern about the pressure that this problem can place on casualty departments? They are likely to receive default patients, as it were, who have failed to get adequate primary care services because of the difficulties with out-of-hours cover. They are also likely to have patients referred to them by locums who are not as familiar with local health care facilities as the local GPs. That is placing a great burden on many of our casualty departments, and they are facing a particular problem with elderly, vulnerable and chronically ill people, who really should not be sent to acute hospitals at all, if that can be avoided.

Mark Simmonds: My hon. Friend makes a very good point. He is absolutely right to say that there needs to be more co-ordinated and aligned commissioning by GPs to avoid these problems. I shall say a little more in a moment about the additional pressure being put on to accident and emergency units since the 2004 contract and the reconfiguration of out-of-hours services.

Howard Stoate: I am listening with interest to the hon. Gentleman. As he knows, I am a practising GP. A matter of great interest to me is that of access to medical records out of hours. The situation is currently extremely difficult, because many practices use different types of software, which cannot "talk" to each other or to the outside world. How does he envisage that problem being solved? The obvious way is through the NHS Spine system and the use of summary care records, but what does he think is the best way of ensuring that the out-of-hours service has access to patient records?

Mark Simmonds: The hon. Gentleman is right to say that there needs to be much more co-ordination and co-operation on the flow of information. The review instigated by the then Minister of State into the terrible tragedy in 2004 does not seem to have been implemented. We need to ensure that there is a cross-flow of information, so that similar tragedies cannot happen in the future. I believe that some of the solutions that I will outline later will help to alleviate some of the concerns that the hon. Gentleman has, both as a practising GP and as a Member of Parliament.
	Increasing concern is being voiced about primary care trusts' over-reliance on foreign doctors, who might not be familiar with British working practices or have the necessary language and communications to undertake the jobs safely. It is currently possible for a foreign doctor to pass a language test in one primary care trust even though they have no intention of working there, then to transfer to another PCT without a second test being taken. There is no standardised English and communications test for doctors from the European economic area who want to work in England; nor is there a mechanism for identifying those who have failed a test. That can result in EEA doctors providing out-of-hours cover in the UK without having undergone any testing in the area in which they are practising.
	This is not new, however. The Government have been consistently warned about the increasing number of failures in the out-of-hours system. In 2000, the independent Carson review of GP out-of-hours cover-the bedrock of the reforms that the Government put in place in 2004-outlined the principle that out-of-hours services should meet patient needs and not be used simply as a holding bay until the GP practice reopens. Too often, however, that is exactly what happens.
	In 2004, the Health Committee voiced its concern that many PCTs did not have the skills to commission services. It warned that GPs should not become disengaged from out-of-hours services, yet that is exactly what has happened. The Committee also highlighted the concern that, if out-of-hours cover were withdrawn or changed, or if access to it became more difficult, demand for urgent care would increase in other parts of the system, such as accident and emergency. That is exactly what has happened. Attendances at accident and emergency departments have risen by 10 per cent. in the past four years alone.
	In 2006, an investigation by the National Audit Office found that most out-of-hours providers were not meeting all the national quality requirements, particularly on speed of response. That is continuing to happen. It was recently reported that only 6 per cent. of PCTs were assessing out-of-hours calls quickly and safely within the benchmark period of 20 minutes. In 2007, a further Health Committee report commented that
	"inadequate performance measurement means that some Primary Care Trusts do not know how good a service they are providing for their patients".
	That is still the case: some PCTs are still not monitoring their out-of-hours providers' performance or reviewing the service regularly.
	Most recently, the CQC, in its preliminary observations from its investigation into a specific provider, identified that trusts do not routinely look in detail at the quality of the care. The CQC also found that primary care trusts have not had a consistent approach to the inclusion of doctors on the performance list, which may have led to some of the problems under discussion. If I have time, I will return to that theme later.
	That is a damning list of warning signals, which have not been resolved. There is, however, a solution to the problem. A growing consensus exists on what needs to be done to tackle the problem. The Government appear to be becoming isolated and alone in not recognising the solution to what is, bluntly, currently a mess. Clearly, the Government made a serious error by removing GPs from responsibility for out-of-hours care. We must urgently review the whole system, as well as returning responsibility for commissioning the service to GPs. That will rebuild the link between GPs and out-of-hours services and result in better co-ordination of primary care services.
	The GP-patient relationship is vital for the performance of the national health service and for improving patient care and outcomes. The Opposition are not advocating a return to a Dr. Finlay style of medicine, with GPs being responsible for their patient list around the clock. However, we recognise that GPs are closest to the communities and patients they serve and are therefore best placed to lead commissioning for a service that best meets patients' needs.

Mark Todd: May I draw the hon. Gentleman's attention to the letter from Dr. Laurence Buckman of the British Medical Association, which is reproduced in the Library pack for this debate? Dr. Buckman's solution is not the one that the hon. Gentleman has just outlined. Does he differ from the BMA on its approach to the problem?

Mark Simmonds: I will come to a comment from the BMA in a moment, but the hon. Gentleman should be cautious: he will be aware that the gentleman to whom he has referred has recently been quoted as saying that the prevalent view among GPs is that the Labour party is the enemy of the NHS. I hope to have an informed debate about out-of-hours care this afternoon, to ensure that Ministers in the Department of Health understand the seriousness of the failings currently occurring.

Norman Lamb: I agree with much of what the hon. Gentleman has said about how the system works at present, but what makes him feel that the approach that he advocates will be different and qualitatively better than what existed before 2004? There were serious concerns about how it operated then, and those concerns led to a movement for reform of the system.

Mark Simmonds: The fundamental difference between what we propose and what happened before 2004 is that we do not necessarily advocate compelling GPs to be responsible for caring for their patients 24 hours a day, seven days a week. What we are advocating, and what we believe is essential if we are to improve out-of-hours and urgent care, is the vital role of GPs in commissioning such services, in which far too often they are not involved at present. There is a direct correlation between excellent and good out-of-hours provision and the involvement of GPs in providing the service, which they should clearly be allowed to do if they so wish. Sadly, some of the tragedies in the recent past occurred when GPs were not involved in such provision.

Mark Todd: May I ask the hon. Gentleman, I hope helpfully, to distinguish between commissioning and governance in his approach? He wants GPs to commission such services, but I very much doubt whether that is what they want. They very much wish to be involved in the governance of such services, and I would wish that to be one of the outcomes of any examination of the service review.

Mark Simmonds: I am grateful for that intervention, but I disagree with the hon. Gentleman. I travel extensively around England to have discussions with GPs and I have encountered genuine enthusiasm for the control of real budgets for commissioning not only out-of-hours care and urgent care, but a wider range of services on behalf of their patient groups. There is no doubt in our minds that the GP-patient relationship is key, that GPs most understand the patients for whom they are responsible and that GPs are, therefore, much better placed to commission their services than primary care trusts.

Norman Lamb: I wish to pursue the point that I raised a little earlier. The hon. Gentleman said that things are different this time because he is talking about commissioning, but I understand that prior to 2004 commissioning was, in effect, being undertaken in many cases; GPs were not providing it directly, but they were making arrangements with other organisations, possibly co-operatives. That arrangement seems similar to what he is proposing now.

Mark Simmonds: We propose that GPs will commission out-of-hours care, but there will certainly not be a compulsion for them to provide that care, unless they have a desire to do so. Prior to 2004, the argument made by GPs and their representatives was that they did not want to provide out-of-hours care because of an issue relating to recruitment into the profession. That argument has gone away, and I detect, from talking to GP representatives and GPs who are practising, a change of view in the past year or 18 months; there is now a recognition that in many parts of the country out-of-hours provision is not working as GPs would desire for their patients and a definite wish to get involved in commissioning. I therefore think that the Conservatives are on exactly the right lines.
	As to the solutions, we require not only an urgent review, but the returning of responsibility for commissioning to GPs. That would rebuild the all-important link; as I have said, GPs are much better placed to commission these services, as they understand their patients' needs most. These services should be commissioned alongside other services, such as accident and emergency services and those dealing with minor injuries, to ensure an integrated model for urgent care, which does not exist at the moment.

Maria Miller: The out-of-hours service in my constituency is delivered in a central location in my local hospital-it is delivered right next to the accident and emergency department. That means that people who could be better served by out-of-hours services can be redirected, thus providing them with better care and, importantly, saving the hospital money. Does my hon. Friend think that that is the sort of model that other areas should be adopting?

Mark Simmonds: It sounds as though an excellent model is being used in my hon. Friend's constituency. We do not think it appropriate to impose from the centre one model to fit across the whole of the country; we think that that is a mistake that this Government have made. Different local solutions will be provided in different local areas. The important thing is that GPs are involved in commissioning, in ensuring the delivery of service and in ensuring that the service mechanism in place is delivering the best patient outcomes for their particular patient groups

Several hon. Members: rose -

Mark Simmonds: I will give way a little later, but I wish to make some progress because I know that many other hon. Members wish to speak in this debate.
	The Conservative position increasingly seems to be being accepted by many other organisations. The NHS Alliance agrees that GPs are best placed to deliver out-of-hours care and recognises the importance of local responsibility for out-of-hours services. The Royal College of General Practitioners is rightly concerned about the quality of services and has called for a "comprehensive review" of out-of-hours and weekend care and for local GPs to be involved in commissioning. Even the BMA, which was mentioned by the hon. Member for South Derbyshire (Mr. Todd), has said in its briefing for this debate that it believes that local GPs should be involved in commissioning out-of-hours care. We welcome that support, because the current system is unsustainable and is not working consistently everywhere as it should be. It must be clear to the Government that the system requires improvement.
	I wish to raise one further issue-the performers list. That list of doctors who are allowed to practise in the UK is maintained by the primary care trusts. There is a need for more stringent checks on the clinical and communication standards of foreign doctors coming to work in the UK. To be fair, the Department of Health produced a very good report early last year entitled "Tackling Concerns Locally: the Performers List system". It is a sensible, well written paper that addresses some of the concerns, but it needs to be implemented-it is not being implemented everywhere.
	The Secretary of State and the Ministers need to be aware of the real concerns of the General Medical Council, and I have a couple of quotes that I want to read to the House. The GMC believes
	"that the current legal framework is unsatisfactory."
	and that
	"the current system does not adequately safeguard patient safety."
	These are very serious issues that the Department and the ministerial team need to look at urgently.

Kevin Barron: The hon. Gentleman might know that I spent nine years as a lay member of the GMC. Does he think that if doctors were commissioning treatment for patients, they would have any professional responsibility for what happened to those individuals?

Mark Simmonds: I support the mechanisms that are in place at the moment-the list that the GMC holds and the providers lists for which the primary care trusts are responsible. There have been failings in the past in that when a primary care trust has rejected a particular doctor for a failure, for example, to be able to communicate in English, that information has not been passed on either to other primary care trusts or to the GMC, which would then be able to regulate and to strike that doctor off the list. In the European Union area, when a doctor is suspended in Germany, for example, that information cannot be passed to the GMC or to PCTs in this country.

Kevin Barron: I completely agree with the hon. Gentleman on the issue of English language testing and the need to be able to communicate with patients. However, my question is if a doctor commissions services for a patient, are they professionally responsible for those services?

Mark Simmonds: Clearly, there has to be a professional responsibility for the provision of health care that that doctor has provided, but it must fit a regulatory structure. That is part of what the GMC is there for.
	The Government need to make immediate changes to improve out-of-hours and patient care. Primary care trusts must monitor and performance manage their out-of-hours contracts much more robustly to ensure that they are offering a high-quality, cost-effective service to patients. Strategic health authorities must take a more proactive role in assessing and monitoring primary care trusts, out-of-hours contracts and performance management. The national quality guidelines need to be reviewed, as they are too generic and do not allow local services to be tailored to local needs. A system in which GPs lead commissioning would make a significant contribution to addressing that issue. The performers list must be reviewed to ensure greater co-ordination and communication between PCTs and the GMC to alert them to doctors who are not suitably qualified. There must also be much greater encouragement and analysis of patient feedback.
	In conclusion, this service is ultimately about patients-patient care, patient outcomes and patient safety. If we are to move to a patient-centric national health service, the level of out-of-hours service provided to the public must, in some areas, improve dramatically and respond to the local needs and requirements of patients. Only if local GPs commission out-of-hours care for their patient groups will patients receive the service they deserve 24 hours a day, seven days a week. If this Government do not act, after the next general election-if we are given the chance-we will.

Mike O'Brien: I beg to move an amendment, to leave out from 'NHS' to the end of the Question and add:
	"welcomes the improvements in out-of-hours and urgent care services over the last 12 years; notes that the Carson report in 2000 identified the need for the reform of out-of-hours care which was carried out in 2004; further notes that by the start of 2004 only five per cent. of patients saw their own GP out of hours; acknowledges that GP organisations say that they do not want a return to the system which existed in 1997; understands the continuing need to improve the quality of out-of-hours care; notes that the Government commissioned the first national out-of-hours benchmark to help primary care trusts and providers improve the quality and productivity of out-of-hours services and to reduce local variation; recognises the improvement in healthcare after the introduction of the GP contract in 2004, which has significantly extended weekend and evening opening of surgeries for routine, bookable appointments; recognises that over 77 per cent. of GP practices now offer extended opening hours and that every primary care trust is developing a new GP-led health centre, open from 8 am until 8 pm, seven days a week, 365 days a year; and welcomes plans for people who need urgent care to be able to dial 111 for advice 24 hours a day, seven days a week.".
	Madam Deputy Speaker, you have already referred to the inquest in relation to two deaths and I am sure that the House will want to join me in sharing our deepest sympathy with the families of those involved. I do not propose to comment any further on these sad matters until the inquest is concluded.
	The Government have made some important changes to out-of-hours and urgent care services. I welcome the opportunity to debate them with the House today. Let me make it clear that out-of-hours care is better than it was in 2004, but it clearly needs further reform. Regulation, in particular, needs much more central drive. I shall return to that point, because it is a clear difference between me and the hon. Member for Boston and Skegness (Mark Simmonds), who, in his speech, willed the end but not the means. It is important that we ensure that we have a system that delivers for patients, and that means making sure that there is effective regulation in place.
	Before 2004, doctors were responsible for the care of their patients 24 hours a day, but growing demands put that system of out-of-hours care under increasing strain. Most GPs worked on a rota basis in local co-operatives, seeing other doctors' patients. Locums were often employed by practices, and some areas employed private companies.
	At the beginning of 2004, about 5 per cent. of GPs provided out-of-hours care for their own patients. We need to be a little cautious about the myths that sometimes surround this matter. The National Audit Office has said that the figures show that the myth that GPs saw only their own patients needs to be challenged. Some of them did that, but the number was relatively small.
	Doctors who saw their own or other doctors' patients as part of a rota were sometimes left exhausted the following day. Before 2004, doctors often turned up for home visits or surgeries exhausted and sleep-deprived, thus putting patients at risk. Dr. Laurence Buckman of the British Medical Association said last week that the old system meant many doctors were tired and therefore potentially dangerous to patients, and that it was for that reason that the BMA and the GPs it represents would resist taking back personal responsibility for delivering care out of hours. I shall return to the question of personal responsibility later.
	Complaints about the old system were building by 1997. By 2000, the level of complaints from the public led the Government to conclude that the existing model of out-of-hours care was unsustainable. Dr. David Carson was asked to conduct a comprehensive, independent review of out-of-hours services in England. His 22 recommendations, accepted in full by this Government, formed the basis for our 2004 reforms of the GP contract with regard to out-of-hours care. The contract released tired GPs from the burden of out-of-hours care and introduced the quality and outcomes framework to incentivise quality.
	The reforms were monitored, both by the Department and independently, in May and July 2006, November 2007, September and November 2008, and September 2009.

Alan Beith: The Minister has described how the Government came to hand over to PCTs the responsibility for commissioning doctors to replace GPs. Where did they think those doctors would come from?

Mike O'Brien: It was clear that many areas would provide the service through various rotas among doctors' co-operatives, which would be commissioned by the PCT and centrally co-ordinated. Other areas would use companies to provide the services, but in a minority of cases the service would be continue to be provided by GPs who wished to opt out of the system and run their own provision. The aim was to ensure a greater degree of co-ordination in the provision of out-of-hours care that would give patients the increased access that they needed.

Alan Beith: But where were the doctors to come from?

Mike O'Brien: The right hon. Gentleman repeats his question from a sedentary position. Most out-of-hours services are provided by doctors who specialise in them, or by doctors working on a rota basis for co-operatives or private sector organisations. Some of those doctors work during the day, but they are obliged to ensure that they do not get to the level of tiredness that was evident before 2004.
	I mentioned that there were various independent and other reviews. The 2006 review of out-of-hours care by the National Audit Office said:
	"England is at the forefront of thinking internationally"
	on out-of-hours care, and that it
	"compares well on cost and quality against the rest of the UK".
	In 2008, the Healthcare Commission's report on urgent and emergency care entitled "Not Just a Matter of Time" added:
	"There have been significant improvements over recent years in the ... number of out-of-hours GP services meeting national quality requirements."
	It went on:
	"These achievements have taken place despite the pressure from the significant growth in demand for many of these services."
	The spending by PCTs on out-of-hours services has risen from £209 million in 2004 to £378 million last year. It is clear that the quality of out-of-hours care for most people is better than it was in 2004 but in some areas, owing to regulation, it is not yet good enough.

Andrew Lansley: What is the measure?

Mike O'Brien: The shadow Secretary of State, who has not deigned to lead this important debate, and did not bother to lead the previous one either, insists on chuntering from a sedentary position and asking what the evidence is. If he looks at the evidence in NAO reports and at the reports that we are going to publish in due course, he will see that it is clear that the standard of care has improved, but it still has a long way to go. We have never said-let me make this clear-that the NHS is a perfect organisation. Indeed, only a short time ago, we published a policy statement about going from "good" to "great". In the next five to 10 years, we need to move the NHS from where it was in 1997, when the hon. Member for South Cambridgeshire and his party were responsible for it, and it was on its knees. We have raised it from its knees, and it is standing up. It is good, but it must now become great. There are real issues that we still need to resolve in the NHS, and we are the first to say so.

Anthony D Wright: I accept that there have indeed been improvements. Although I disagree fundamentally with the Opposition motion, which is a step backwards, there are particular problems in my area, where Take Care Now failed on two occasions in the last week to deliver a doctor on time. Only on Saturday, a family friend called the out-of-hours service at 9.30 am, but the doctor did not arrive until 5.15 pm. Does my right hon. and learned Friend accept that we need significant improvements in those areas before we can say that we have a very good service? I reiterate that turning the clock back is not the way forward.

Mike O'Brien: My hon. Friend is quite right-we cannot turn the clock back. We need to improve the quality of care provided by out-of-hours services, and that is what we are committed to do. I do not want to comment on the organisation to which he referred, because there are issues relating to the inquest that is under way. Generally, however, we accept that the way primary care trusts make provision must be improved. I want to discuss levels of control, because the Opposition have suggested that there is a lack of control.

Mark Todd: Will my right hon. and learned Friend give way?

Mike O'Brien: If my hon. Friend will forgive me, I need to make progress, as other Members wish to contribute to the debate.
	Patients must have confidence in all the medical care they receive, regardless of when, where or from whom they receive it. There are three key levels of control on the quality of GPs. First, the General Medical Council certifies whether someone has the appropriate qualifications. Whether they are a foreign national coming from the EU or otherwise, we must look at how we recognise those qualifications. Secondly, PCTs, which commission NHS providers, have legal obligations under the 2004 regulations to check GPs before they go on the performers list. That is not optional, as I am sure the hon. Member for North Norfolk (Norman Lamb), who will speak next, if you wish him to do so, Madam Deputy Speaker, ought to know. It is a legal requirement, and the National Health Service (Performers List) Regulations 2004 state clearly in regulation 6(1)(e) that the grounds on which a PCT may refuse to include a performer in its performers list include
	"any grounds for considering that admitting him to its performers list would be prejudicial to the efficiency of the services, which those included in that list perform."
	The regulations also state that a PCT "must" refuse to include a performer on the list if
	"it is not satisfied he has the knowledge of English which, in his own interests or those of his patients, is necessary".

Norman Lamb: Can the Minister specify the consequences of breaches of the regulations which allow a doctor to practise, to go on to the performers list and potentially to cause risk to patients?

Mike O'Brien: If a doctor did not carry the required level of knowledge and the ability to speak English, they could, if they were not competent, be referred to the General Medical Council. That is a professional issue. The GMC is able to deal with it and take action to remove that person's right to practise if that is appropriate. However, there are two other levels of control.

Several hon. Members: rose -

Mike O'Brien: It is important that Members understand there is not only the GMC, which was mentioned by the hon. Member for Boston and Skegness, who spoke for the Opposition. The second level of control is the primary care trust which commissions the services. It must put in place robust arrangements to ensure, through the contracts, that out-of-hours services are using GPs who are fit to practise and can deliver appropriate and skilled medical practice, including the ability to speak and understand English.
	PCTs were reminded of those duties in the Healthcare Commission's national review of urgent and emergency care in 2008-

Mark Simmonds: Will the Minister give way?

Mike O'Brien: No. I shall make progress, then I will give way to some people. I say a few words and am then interrupted almost immediately. There are others on the Back Benches who want to make a contribution, so if the hon. Gentleman will forgive me, I will give way to him a little later.
	PCTs were reminded of these duties in the Healthcare Commission's national review of urgent and emergency care, which again concluded that out-of-hours care had improved, but warned that PCTs should scrutinise their out-of-hours care more closely to meet their legal responsibilities to provide safe, high-quality care.
	The third level of control is the employer. This can be the PCT or, more often, a company or co-operative contracted by the PCT. The employer should be contractually bound by the PCT to check qualifications and ensure that the GPs it employs are competent. That is part of the basic controls. In October 2009, the CQC issued an interim statement on its inquiry into the provision of out-of-hours services by Take Care Now to remind PCTs that they were already obliged to have in place robust arrangements for commissioning and for performance and contract management. The CQC emphasised the need for PCTs to assure themselves that all out-of-hours GPs, including locums, are fit to practise.

Several hon. Members: rose -

Mike O'Brien: Out-of-hours providers were also reminded of the need to ensure rigorous recruitment, induction and training arrangements for medical staff. Dr. David Colin-Thomé, the national clinical director for primary care, followed this up with a letter to all PCT chief executives. The quality of out-of-hours care is good for most patients, but as we know from the CQC report, there are clearly some serious issues to address.
	Dr. Colin-Thomé and Professor Steve Field, the chairman of the Royal College of General Practitioners, were asked by me in September to examine all the various reports-there are a number of them, going back to Carson-and to make further recommendations on how primary care out-of-hours services could be improved. It is my intention to publish that report as soon as the current inquest has concluded and I have informed the coroner of that.
	I expect the report to show, among other things, that not only have things improved since 2004, but that decentralised controls on PCTs have led to an unacceptable variation in their enforcement-a similar conclusion to the CQC report in October-and that more action is needed to ensure that PCTs perform their control obligations under the 2004 regulations. Before I go on to say a few more words on regulations, I shall give way to hon. Members who have indicated a wish to intervene.

Norman Lamb: I am grateful to the Minister for giving way again. He talked about the regulations that were in place, with which PCTs were obliged to comply by applying the performers list. What are the consequences for the primary care trust of failing to comply with those regulations? The consequences could be fatal.

Mike O'Brien: The fatality relates to the patients, but the primary care trusts would clearly be in breach of their legal obligations, and they would then be subject to NHS disciplinary action. Whether they would be prosecuted on a criminal basis is a separate matter; the situation would involve a breach of civil regulations, so the PCT would be answerable through the NHS.

Mark Simmonds: The Minister mentioned that some primary care trusts were clearly not fulfilling their obligations under the current regulations. He may be coming on to this point, but what specifically will he change to ensure that PCTs abide by the regulations, that such tragedies are prevented and that service improvements take place?

Mike O'Brien: I am indeed going to come on to that.

Jacqui Lait: My hon. Friend the Member for Boston and Skegness (Mark Simmonds) mentioned that doctors from the European Economic Area do not have to take a language test, and I seem to remember that that comes from the directive on the free movement of workers. Will the Minister clarify whether they still do not have to?

Mike O'Brien: They do not, and that is an important point. A doctor from the EEA-comprising the European Union and a couple of other countries-does not have to carry out a language test for the GMC; other doctors from outside the area do. However, the PCTs are therefore obliged to ensure that a GP who is employed to provide out-of-hours care or other services can speak good English. The PCT can insist on tests and on the provision of evidence to show that the individual GP speaks good English.
	A general examination of a number of PCTs has shown that some have not carried out the level of tests and checks that they are legally obliged to undertake on a person's ability to speak English. If someone applies in Nottingham or Leeds, for example, they will undergo checks. Other PCTs were not carrying out checks. I understand that Cornwall was not carrying out adequate checks, but I am told that it is now. That issue needs to be clarified.
	The PCT is not the only body that must check whether someone speaks English before they go on the performers list: the employer should, through its contract, have an obligation to ensure that the doctor is not only a competent clinician, but able to speak English and communicate with the patient. It seems pretty basic to me.

Mark Todd: My right hon. and learned Friend's response provoked me to add my name to the debate, so he will get more value from my words than he might otherwise have had. May I draw his attention to the concern of those suffering from motor neurone disease? I, along with two other Members who are present, sat through presentations from sufferers of that condition who had used the out-of-hours service. It is a rare condition, but the lack of knowledge displayed by the person with whom they were dealing made that experience deeply distressing. The training level and protocol strength that the out-of-hours service uses must be radically reviewed in that context.

Mike O'Brien: My hon. Friend makes a very good point, which I shall certainly take on board. I look forward to hearing his further contribution, if Madam Deputy Speaker so wishes, during the course of the debate.
	I now turn precisely to the level of regulation. This Government take patient safety so seriously that we have strengthened the regulations on health care providers, but the hon. Member for Boston and Skegness made it clear that the Opposition oppose further regulation. There is always a question as to how prescriptive regulation should be and where the balance should lie: should we try to control more from Whitehall with more interventionist regulation? However, one cannot run everything from the centre. Despite what some people say, Nye Bevan did not make himself responsible for every bed pan dropped in Tredegar. We rely on local managers, and the policy needs to be in place so that they know what they have to do; then the regulators must be there to check that local managers know what has to be done and implement it. Nevertheless, we cannot guarantee that human fallibility, negligence or failures might never arise.
	Should we leave it to PCTs and employers to enforce safety practices and checks? Decentralisation is beneficial in the sense that it can deliver innovation and respond to local needs; it also sounds good and makes a good soundbite, as we heard from the hon. Member for Boston and Skegness. However, it can produce risks in some parts of the system if those parts do not deliver what they are supposed to. More regulation may therefore be needed in the case of out-of-hours care. I will be able to make some further announcements in a report that we will publish in due course.
	We have recently made a number of significant changes. First, the Care Quality Commission has now replaced the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection as the single regulator for all health and social care. This more powerful and more effective system of regulation will help to ensure a more consistent approach to patient safety, no matter where people are being treated or cared for and no matter who they are being treated by, whether it be public or private sector providers. This system of stronger regulation is being rolled out. By April 2012, subject to legislation, all providers of out-of-hours care, including private companies, will need to register with the CQC, giving it a greater degree of scrutiny and independent oversight.
	Secondly, we have changed the standard of proof for professional disciplinary cases from that of beyond reasonable doubt to the more flexible and more appropriate civil standard balance of probabilities.
	Thirdly, in November last year, we introduced a licence to practise. This will ensure that doctors must continue to meet the high standards demanded of the profession throughout their careers by requiring them to go through a process of revalidation every five years to prove that they continue to meet the standards. This will be the only systematic and comprehensive system to assure the quality of doctors anywhere in the world. As part of this process, doctors must also now present annual, clear, positive evidence of their fitness to practice against 12 standards based on the GMC's "Good Medical Practice".
	Fourthly, from October, subject to regulations, health care organisations will have to appoint a responsible officer with a statutory duty to evaluate a doctor's fitness to practise and to monitor their conduct and performance. They will also monitor admission to the performers list.

Maria Miller: Will the Minister give way?

Mike O'Brien: Let me deal with a couple more points, and I will give way before I conclude.
	The hon. Member for Boston and Skegness asked about the implementation of electronic patient records. More than 1 million core records have been created across a number of locations, including London. Early evidence points to improving out-of-hours care, ensuring that doctors have up-to-date information at their fingertips in situations where this is critical. It is not yet available across the country, but it is rolling out as we speak. With the IT systems and the changes that we are making to improve the quality of care, which the Conservatives have indicated that they are unhappy with, we are ensuring that that sort of information is more readily available.
	In terms of the broader issues, the results of massive investment in the NHS in 2001 are now becoming clear. More than 98 per cent. of patients are being seen, diagnosed and treated within four hours of arriving at A and E. Three quarters of GP practices now offer extended opening hours-a move that was opposed by the Conservatives. New GP-led health centres are being opened in every PCT area, opening from 8 am until 8 pm, seven days a week, 365 days a year-also opposed by the Conservatives. Millions of people use NHS Direct for clear and accurate information about medical issues and to seek help by day or night. We plan to introduce a free 111 urgent care phone number, to go alongside the traditional 999. That will help with anything from making an appointment with an emergency dentist to directions to a late-night pharmacist or referral to an out-of-hours primary care GP.
	The reforms that we put in place in 2004 have improved the quality of out-of-hours care for patients and were introduced with the support of the medical profession. We have brought the system from poor to good, but we have never claimed that it has got to where we think it should be. There is more that we can do, and we need to make it better. When I asked Dr. David Colin-Thomé and Professor Steve Field to report, I asked them to examine with care all the evidence in relation to out-of-hours care. They will make recommendations to strengthen the system of regulation and improve patient safety, and I look forward to sharing those recommendations with the House in due course.
	The Conservatives have indicated today that they want to return responsibility for commissioning out-of-hours care to GPs. I was particularly struck by the answer given to my right hon. Friend the Member for Rother Valley (Mr. Barron) when he asked what the responsibility implications of that were. It appears that responsibility for out-of-hours care is to be handed back to GPs. The Conservatives want to force a number of things on GPs, including hard budgets for patient care. GPs are concerned that forcing them to hold responsibility for out-of-hours care, on top of those hard budgets, could drive some practices to the wall, but the Tories would force those things on all GPs. The Government say that under practice-based commissioning, GPs can already take on the commissioning of out-of-hours care and budgets if they want to, but we will not force them to if they do not. It appears that there is a clear dividing line between the Conservatives and ourselves.
	The Conservatives claim that they are concerned about the NHS, but in 1997, 18 years of a Conservative Government had left it on its knees and struggling, including out-of-hours care. When we increased national insurance to improve the NHS, including out-of-hours and urgent care, the Conservatives opposed it. When we set a four-hour target for accident and emergency patients to be seen and treated, discharged or admitted, they opposed it. When we created GP-led health centres offering extended hours to patients, they opposed it. When we extended GP practice opening hours, which has now happened for patients at 77 per cent. of practices, the Conservatives opposed it. When we introduced the target for patients to see a cancer specialist within two weeks of referral, they opposed it. They want to set the clock back on the NHS and its reforms and remove the targets that have improved services.
	We have never said that the NHS has resolved its problems-far from it. With our policy of "good to great" we have said precisely the opposite: there is still more work to be done on the NHS. We have got it from poor to good, and we now need to get it from good to great. We need to ensure that we reform out-of-hours and urgent care as part of that change. We have shown our willingness to tackle the problems in the NHS and are not satisfied with the current state of things, which is why we commissioned proposals to improve out-of-hours care.
	In the coming months, we will expose the complete vacuity of the Tories' policy. Their claims of over-regulation are the opposite of the truth, which is that we need tough regulation in this area. The Labour Government have shown that we can deliver it. We are the Government who care about the NHS and who will deliver improvements in the NHS.

Norman Lamb: May I first join the Minister in expressing my deepest sympathy to the families of those whose deaths are subject to the inquest that you referred to, Madam Deputy Speaker?
	It is clear that what the hon. Member for Boston and Skegness (Mark Simmonds) said is right, and that the quality of out-of-hours care is not good enough across the whole country. Standards are variable, and there are insufficient safeguards to protect patient safety. It is fair to say that there are very good services in some parts of the country, and they should be recognised. It is also right that cost is not the key factor; some good services are provided at a relatively low cost and some poor services are clearly expensive to the local health economy.
	It is also right to point out that the reform that was introduced alongside the GP contract in 2004 was flawed in its implementation. My right hon. Friend the Member for Berwick-upon-Tweed (Sir Alan Beith) made the legitimate point that an assumption seems to have been made at the time that there was a pool of doctors in every locality who would be readily available to provide out-of-hours care. Of course, the truth was very different.
	In many parts of the country, including my right hon. Friend's area and my area of Norfolk, the out-of-hours services has had to rely to a greater or lesser extent on doctors being flown in from overseas. That is not acceptable. It often means someone flying in on a Friday evening ready for a weekend session, tired and too often not sufficiently cognisant of the local health arrangements. That failure of the 2004 reform needs to be recognised.
	However, it would be wrong to imply that everything was good before 2004. I am worried that the Conservative proposal to return commissioning responsibility to GPs appears to be a return to what was happening in many parts of the country before 2004. In 2004, immediately before the reform, few patients saw their own doctor out of hours. In most cases, GPs were entering contractual arrangements with other bodies, often co-operatives, to provide that care. That seems to be exactly the commissioning arrangement that the Conservatives propose. I agree that reform is necessary, but I am concerned about a knee-jerk reaction and going back to a previous system, which clearly had serious flaws and was greatly criticised at the time.
	Why is out-of-hours care so important? Self-evidently, critical decisions often have to be taken outside the normal hours that GPs operate-often in the dead of night, often in very rural areas. It is vital that patients can rely on high-quality care at those times of need. It is critical that we provide the reassurance to people that, when a crisis occurs in the middle of the night and they make that phone call, they will get a responsive service and that the GP who is available to turn up is of a sufficient standard. Concerns were expressed that the whole rural county of Suffolk is served by two GPs out of hours. Surely we can all agree that that is unacceptable for providing a trusted service.

Alan Beith: In a situation that often arises, when a family with a sick child has to decide whether to ring the out-of-hours doctor, who may arrive in two hours from 60 or 70 miles away and may then call an ambulance, they tend to call the ambulance straight away, because at least the child will then be taken to hospital, even if that is not the right clinical decision.

Norman Lamb: My right hon. Friend is right. That can result in unnecessary admissions to acute hospitals, which are already overburdened. There have been significant increases in admissions to accident and emergency. In an intervention from the Conservative Benches on the hon. Member for Boston and Skegness, the point was made that, if we end up with transfers of care to acute settings, it is more inconvenient for the patient and costly for the health service, and thus wholly counter-productive.
	The hon. Member for Great Yarmouth (Mr. Wright) made the point that in the recent past in his area, his constituents had to wait hours for a doctor to turn up at their time of need. Just imagine the anxiety that those people go through while waiting for a doctor to arrive. I am sure we all agree that that is not acceptable.
	The best situation-I draw the distinction between the provision of care and the commissioning of care-is surely when, as far as possible, GPs who have an involvement in the local primary care system are involved in the provision of out-of-hours care. Some doctors could work shorter hours in in-hours time and commit to out-of-hours care. That happens in some places.
	We must recognise, however, that doctors are under significant pressure, and that one reason why the change was made in the first place is that we were finding it difficult to recruit doctors because of the commitment to 24-hour care. Any reform must recognise those pressures and understand that we cannot push doctors over the edge. Exhausted doctors are also not good for patient care.

Robert Syms: The hon. Gentleman makes a good point. However, there are also a lot more women doctors both in hospitals and among GPs-that is one of the major changes in the profession-and they may have family obligations. It would be difficult for them to give the same level of out-of-hours care when they have children to look after.

Norman Lamb: That is a very fair point. I was previously a solicitor. Some women solicitors joined a rota to provide out-of-hours support under the legal aid scheme. It is not impossible, but I recognise that there are constraints, and I accept the hon. Gentleman's point.
	We can all agree that the concerns about the use of foreign doctors in out-of-hour care need to be addressed. I fully understand the sub judice nature of the current inquest, so I will not refer to it, but I will refer to the current framework, which I think is inadequate to protect patient safety. A doctor must get on to the performers list before he or she can practise in any given area. However, once a doctor is on a performers list, in any part of the country, they have access to practise anywhere around the country. Failures by one primary care trust could be fatal in any part of the country, not just that area.
	Back in February 2007, my hon. Friend the Member for Truro and St. Austell (Matthew Taylor) expressed concerns about Cornwall and Isles of Scilly PCT in a debate in Westminster Hall. He highlighted specific cases of constituents who had to deal with doctors out of hours who could not understand their patients. Surely that is unacceptable. Of one case, he said:
	"Mr. and Mrs. T were gobsmacked when their daughter was seen by another overseas agency doctor who not only found it difficult to understand her-this has been an issue with the overseas doctors employed-but relied on an electronic word converter to communicate with the patient."-[ Official Report, 20 February 2007; Vol. 457, c. 4WH]
	That is utterly shocking. How did that doctor get on to the performers list in Cornwall? As I asked the Minister earlier, what are the consequences of the abject failure of that PCT to prevent that doctor from practising out-of-hours care in Cornwall?

Mark Simmonds: The hon. Gentleman makes a very powerful point. Is he aware that rumours are circulating among GPs that one or two PCTs have a reputation for giving easier access to the performers list? As a result, GPs who cannot communicate, and who perhaps do not understand the medicines that are used in the UK, have been able to get on to the out-of-hours circuit and provide care for patients.

Norman Lamb: I am aware of that and I am grateful to the hon. Gentleman for raising it.
	At the end of that debate, my hon. Friend asked the Secretary of State, who was then a Minister:
	"Will the Minister promise to take a personal interest in ensuring that the situation is rapidly turned around?"
	He answered:
	"I give the hon. Gentleman that commitment, because these are extremely important concerns."-[ Official Report, 20 February 2007; Vol. 457, c. 24WH.]
	Yet it seems that the practice of allowing doctors to be admitted on to the performers list in that county continued for some time afterwards. The Minister says that that has changed now, but what guarantee do we have that any particular PCT will not have flaws in their system and allow a GP into the system who can then practise anywhere in the country? That issue surely needs to be addressed.

Mike O'Brien: Does the hon. Gentleman agree that it needs to be addressed by ensuring that regulations are more effectively enforced and, if necessary, tightened up? That means that the Government have a role, contrary to the view of the official Opposition. Regulation may have to be tightened up in that area.

Norman Lamb: I am grateful for that intervention, and I agree that the rules have to be tight and effective. If a primary care trust allows doctors to practise, in effect anywhere in the country, by allowing them on to the performers list when they are not competent and cannot speak the language-in other words, in breach of the regulations that the Minister mentions-it should be a criminal offence on the part of the PCT. I would like the Government to commit to investigating that possibility, because there is a powerful case for it. There have to be consequences for a failure by the PCT in allowing an incompetent or dangerous doctor to practise in this country.

Mike O'Brien: Criminal penalties involve someone having to pay a price, be that a fine, imprisonment or something else. What sort of penalties does the hon. Gentleman propose PCTs should be subject to? After all, patients would lose out if a fine were levied, because it would come from the budget. Who should be imprisoned or convicted of a crime? He needs to think that suggestion through.

Norman Lamb: Of course the idea requires thinking through, but trusts can be criminally liable, if they behave in a way that breaches the criminal law. Some sanction is necessary to concentrate the minds of decision makers, which were clearly not concentrated when allowing doctors into the system in Cornwall, as revealed in that debate.
	As other hon. Members have said, the Department of Health commissioned a report on the performers list, which was published on the website last March. It said:
	"We also concluded that there are unacceptable variations in the way in which PCTs in England currently operate the Performers List arrangements, and have made a substantial number of recommendations to improve the local implementation of the system."
	That report sat gathering dust for many months. I understand that Steve Field is now examining the report and making recommendations of his own, but for too long its recommendations have not been implemented on a national level, and I do not understand why not. Given the flaws in the system that the report revealed last March, the recommendations should have been implemented straight away.
	Registration with the General Medical Council is another vexed issue. We have already heard that if doctors come from the European economic area, they have no obligation to prove competence or language skills before being registered by the GMC. However, doctors from the Indian subcontinent, who might have excellent training and skills, have to prove that they are competent and have language skills before they can be registered by the GMC. In my view, that is discrimination and should not be allowed.
	It seems to me that there is an obligation on us all to argue the case for reform in Europe to ensure that the GMC can test for competence and language skills before any doctor from the European economic area practises in this country. The case for it is overwhelming, and it seems to me that if we believe in the principle of the freedom of movement of labour, which I fundamentally do, there must be a commensurate system of safeguards to protect patient safety. We are not talking about hairstylists; we are talking about people who could kill patients, if they are incompetent or worse. The system does not adequately protect patients in those circumstances. The GMC, when one talks to it, confirms that it is unhappy with the current European framework, and yet the system continues to fail to safeguard patient safety.
	It is fair to say that the system and the quality of regulation around Europe are of highly variable standards. Many European countries have not yet split the trade union function, which here is performed by the British Medical Association, from the function of regulation. That is a conflict of interest, and yet under the current system we have to rely on a regulator that also acts as a trade union in another country to judge the competence of a doctor. That, to me, is not acceptable for safeguarding patient interests in this country.
	A damning report on the quality of general practitioner training in Germany was published in Germany by a panel of invited international experts. It condemned the quality of GP training in Germany, and yet we have to rely on its system of regulation to prove that a doctor is competent to practise in this country. Reports in Germany demonstrate that we should not rely on that before accepting a doctor for registration in the United Kingdom. In my view, that needs to change. However, the fact that it is European law that needs to change should not stop us arguing the case for reform.
	Surely there needs also to be a system for training and assessment when a doctor arrives in this country. If he or she arrives for his or her first weekend shift, surely before that shift is undertaken, there should be full training, both in-hours and out-of-hours, in that local system, before they are permitted to practice in that area. Surely the training should include a full understanding of the "British National Formulary"-the guidance provided on prescribing. The drugs used in this country are often different from those used overseas, and yet we have nothing to require a doctor to understand what drugs are available in this country and what the official guidance is on prescribing. That, again, is surely unacceptable.
	Surely there should also be an absolute requirement for induction, to work with GP surgeries locally to understand how the system works locally and to have an induction in out-of-hours care before such doctors are given responsibility for patient safety.

Alan Beith: I can give an example of the problem to which my hon. Friend is referring. Practice differs in rural areas from urban areas. We have had doctors from overseas, and even UK doctors, who say, "Oh, I don't do stitching, because that is not done in general practice in some areas." In a rural area, however, it has to be, because otherwise the patient might have to travel 60 miles for treatment elsewhere.

Norman Lamb: Absolutely. My right hon. Friend makes the point very well; before a doctor can practise in a particular rural area, with its particular distances between patient and hospital, they must be able to undertake the work to provide a proper service to those patients. He makes that point extremely well.
	Surely it is also the case that, when a doctor in the UK practises, they have to undergo an enhanced criminal records check, but that is not the case with a foreign doctor coming to work in the UK. That foreign doctor might have committed offences elsewhere in Europe, but there is no effective check before they are allowed to practise in this country.
	I want to deal briefly with what happens when something goes seriously wrong. When a doctor is suspended in any European country, there is no obligation on the regulator in that country to notify other regulators in Europe or to pass on information to them. The General Medical Council dealt with that in a letter to me, stating:
	"Our central concern is that disclosure arrangements for this information are voluntary, and rely on individual regulators being able to build effective mechanisms for co-operation between themselves...There is no legislation at European level that requires regulators to share information about a doctor (or other healthcare professional) when action is taken with regard to their registration."
	The letter continued:
	"We have argued that, in addition to the right to receive treatment in another member state, patients should also have the right to safe and good quality healthcare and, as part of this, the right to know that the doctors (or other healthcare professionals) who treat them are safe and fit to practise. Without a legal duty to proactively exchange fitness to practise information, there is a risk that a doctor who held registration in more than one jurisdiction could be barred from practising in one country, while continuing to practise in another."
	That is an horrendous situation, and it is not just patients in this country who are at risk; it is patients across the European Union, because of an inadequate system to safeguard patient safety. We should challenge that.

William McCrea: Having pointed out serious flaws in the present system, perhaps before he finishes the hon. Gentleman will tell us how he believes the situation can be rectified.

Norman Lamb: The GMC is arguing for the reform of directives in Europe. Indeed, it is already lobbying for that, pointing out two different mechanisms in its letter by way of amendments to such directives. I want to know whether the Government are arguing the case strongly in Europe for that change to happen, because it is essential that it should happen in order to safeguard patient safety. When someone is suspended in one European country, surely that suspension should apply across the entire European Union. If we allow people to move around Europe to work, there must be a commensurate safeguard, so that when one regulator decides that someone is not fit to practise or that there is a need to suspend them pending investigation, that suspension should apply across the board.

Howard Stoate: Can the hon. Gentleman not see that he is getting to the nub of why the previous system did not work? He will remember that before 2004 and the new GP contract, each GP was legally liable for the out-of-hours service, even if he or she did not provide it themselves. That meant that should a GP, in all good faith, take on a locum who happened to be a German or French national, that GP was responsible for checking whether that locum was registered and had the right qualifications, training and Criminal Records Bureau checks. For obvious reasons, GPs felt victimised when something went wrong, because the GP who had employed the locum was legally liable for that locum's actions. That is precisely why GPs were so frustrated and angry about the previous system and why they voted so overwhelmingly to divorce themselves from out-of-hours care and hand it to the primary care trust, which at least had the power and a reasonable level of bureaucracy to enable it to address some of those issues, which, in all honesty, could not be addressed by individual practitioners in individual practices.

Norman Lamb: That is the reason why I have concerns about the Conservative proposition. I am not entirely sure whether the shadow Minister said that the commissioning GP would be legally responsible and accountable for any errors made by someone who had been commissioned to provide the service-I do not know whether he wants to intervene on me about that point.

Mark Simmonds: indicated dissent.

Norman Lamb: He does not. That point looks like work in progress to me, but it is a critical issue. My problem with the analysis given by the hon. Member for Dartford (Dr. Stoate) is that accountability is lacking under the current system, too. When a PCT fails to safeguard patient safety by allowing a dangerous doctor or a doctor who cannot speak the language on to the performers list, as we saw in Cornwall, there is no comeback for that primary care trust. That surely has to change.
	I am also concerned about the situation that exists under European arrangements. A doctor who commits an error for which he is potentially criminally culpable must surely be held to account in the jurisdiction of the country where that error occurred. We cannot guarantee that that will happen at the moment, and that must surely change. That will involve ensuring the effective operation of the European arrest warrant, but at present we cannot be confident about that either.
	There is a clear, powerful and overwhelming case for reforming the system of out-of-hours care. The head of the Royal College of General Practitioners, the highly respected Steve Field, said last autumn that there was a pressing case for the reform of out-of-hours care. That case is overwhelming. I have concerns about the proposition put forward by the Conservative party, and that is why I propose that the Royal College of General Practitioners, which is respected not only by practitioners but in this place, should be commissioned to carry out a review and to come up with proposals to reintegrate doctors into the provision-not the commissioning-of out-of-hours care locally, so that we can ensure that patient safety is protected.

Several hon. Members: rose -

Mr. Deputy Speaker: Order. I remind the House that there is a limit of eight minutes on Back-Bench speeches. The Front Benchers have taken up the lion's share of the debate, to the detriment of the interests of Back Benchers, but I hope that hon. Members will try to keep within that limit.

Howard Stoate: Thank you, Mr. Deputy Speaker. I shall endeavour to keep my remarks within your eight-minute time scale.
	This has been an interesting debate that has raised important issues about the quality and delivery of out-of-hours services in general practice. The hon. Member for Boston and Skegness (Mark Simmonds) highlighted the problem well when he said that the present system was patchy. In many parts of the country, it is unacceptable. We need to do something radical to change that, to ensure that patients in every part of the country have access to good-quality out-of-hours services from whomever is delivering them.
	The problem is that I do not agree with the hon. Gentleman's analysis of what needs to be done. He seemed to imply that a return to the old GP commissioning system would somehow improve the situation and put things right. It could well do that in some parts of the country, but it is a rose-tinted view of the situation. This takes us to the nub of the problems that we had before 2004. Some GP commissioners are undoubtedly of extremely high quality and extremely highly skilled, and undoubtedly take a great interest in the service and do a first-class job, but the fact is that most GPs do not want directly to commission. A recent publication by David Colin-Thomé, the national director for primary care, acknowledged that many GPs were not skilled or interested in direct commissioning, and simply did not want to do it themselves. My worry is that compulsorily bringing GPs back into the commissioning role would work in some places but not in others. In other words, we might have a different patchwork, but we would still have a patchwork.
	We need to consider why GPs were so keen to divest themselves of their responsibility for out-of-hours care in 2004. They voted overwhelmingly to end the situation in which they were legally responsible for what happened out of hours. I personally know GPs who had been on holiday and who received a complaint when they got back because of the actions of a deputy who had been doing the out-of-hours care for them. The GP, who might have been sunning himself in Spain at the time, was legally liable for the deputy's actions. That was nonsense. It would not occur in any other situation; why should it occur in general practice? Let us also bear in mind the fact that, before 2004, most GPs did not deliver their own out-of-hours services. They contracted them out to deputising services, to co-operatives or perhaps to an in-town rota. Nevertheless, they were legally responsible for the services provided.
	It is hardly surprising, therefore, that GPs decided that the situation was unsustainable. If we did the work ourselves, we were worn out the next day and not able to provide the top-quality service that our patients deserved. However, if we divested ourselves of the service and gave it to, say, a commercial service, we remained legally responsible. We were never able to sleep soundly in the knowledge that someone else was truly responsible for our patients. The situation clearly could not continue. It was affecting recruitment and retention, and GPs were retiring early because they simply could not keep it up any longer. The situation was untenable and could not continue indefinitely.
	The Government therefore, quite rightly, renegotiated the contract in 2004, and made primary care trusts responsible for the delivery of these services. In most cases, the PCTs simply continued to contract with the same bodies that had already been providing the out-of-hours care. In my area, for example, an organisation called Grabadoc, which covers Greenwich and Bexley doctors on call, was almost entirely staffed by GPs before the 2004 contract, and it got the contract to continue to provide the same service, so almost nothing changed. The only thing that changed was that the responsibility was taken away from the individual practices. That is how it should be.
	If anything needs to be learned from this afternoon, it is that we should be much tougher in regulations-I agree with the Minister-to ensure that primary care trusts can be held accountable to deliver the service that they contract. They are legally responsible to provide the service, so it is up to them to monitor it. It is then up to the CQC, perhaps, to monitor whether the PCTs are doing their jobs. If not, they need to be held to account in whatever way is deemed appropriate. That is not a matter for this afternoon, but it needs to be done properly.
	In the limited time available, I also want to say that the situation is not all bad. It is easy to concentrate on situations in which something has gone wrong, a patient has suffered harm, or a patient's family has waited an unnecessarily long time for a service, and to assume that the service is generally not very good, but that is not the case. We must differentiate carefully in-hours care, when a GP, who is generally known to the patient, will provide a service with a wide range of back-up, practice nurses, diagnostic equipment, access to colleagues within the hospital or community services, and the full armamentarium of interventions. Out-of-hours provision has never been like that. It has always involved an individual practitioner, generally on their own, making an assessment of a patient they probably do not know, and trying, with the limited resources, interventions, diagnostics and treatments available to them, to provide an emergency service for that patient. It has worked well over the years, and some of the evidence is quite interesting.
	I have done some reading of  The British Journal of General Practice, as Members would expect, and it clearly draws a distinction. A paper a year ago said:
	"When dealing with acutely ill patients in usual in-hours clinic circumstances, the support provided by a competent team in familiar surroundings cannot be underestimated. Not only is the patient likely to be known to the practice, but triage, emergency equipment and diagnostic assessment can also be arranged most effectively".
	It continued:
	"In the out-of-hours situation, however, particularly if a home visit...is involved, the GP must deal with many of these aspects alone...clinical decision making is inherently more difficult because patients are much less likely to be known, and options for adequate diagnosis and subsequent patient care are more limited".
	It goes on to make the point that GPs vary considerably in their attitude to risk taking. Many GPs can handle far higher levels of uncertainty of risk than others, and therefore perhaps are better placed to make out-of-hours decisions. It is wrong to assume that all GPs are similarly skilled and competent and that all GPs will provide the same decision making in different situations. Certain types of GPs might be much better placed to make such decisions-that is the direction we are going in-and those GPs often become sessional doctors for co-operatives or out-of-hours services because that is their particular skill and interest. They can provide a better service. The situation is very complex, and one size does not fit all. There are different types of doctor in different parts of the country.
	Another study carried out in south Wales, and published in the  Emergency Medicine Journal in 2008, made a similar point. It found that 80 per cent. of patients were satisfied with the service they received from the out-of-hours service involved. Only a fifth of patients were dissatisfied with the service. The authors examined why those patients were dissatisfied, and concluded that it was due to
	"a mismatch between patients' expectations of the service and what the service actually provides to some specific user groups."
	They concluded that, generally, the service was adequate, but the communication between the patient and service provider was often poor. That point has wide relevance. Quite a few of the worries about out-of-hours care concern a failure to arrive at a clear definition of what an out-of-hours service should provide to patients. Better communication is essential if we are to address that and ensure that patients get the best of the deal.
	Previously, most patients were reluctant to call their own doctor out to make a home visit at night, knowing that that doctor would have to carry on their normal surgery the next day. On the few occasions they did call the doctor out, expectations were generally modest. They were so grateful that their own doctor had come to see them that they were reluctant to put abnormal demands on that doctor. A lot of unmet need was out there, and it is wrong to assume that needs were being met because their own family doctor-

Mr. Deputy Speaker: Order.

Malcolm Moss: In the light of Madam Deputy Speaker's ruling at the outset of this debate that the case of my constituent, Mr. David Gray, remains sub judice until the inquest on his death finishes next week, I shall not allude to it any further. However, I put on record my intention to pursue a proper debate on the circumstances surrounding his tragic death and subsequent developments at a later time and through other means. I am sure that Mr. Gray's family will greatly appreciate the offer of condolences that the Minister made in his opening remarks.
	Several cases in the media in the past years-and not just the case that is currently sub judice-have highlighted the failure of the out-of-hours care system. All too often, we hear similar stories of patients not receiving the out-of-hours care that they are entitled to under the NHS. Currently, the shortage of out-of-hours GPs is largely met by foreign doctors who register to work as supply doctors in England, but the system does not adequately ensure that these foreign doctors are fit for practice. Loopholes in the out-of-hours system have enabled some foreign doctors who should never have been allowed to work as GPs in this country to do so, at great cost to patients' welfare and safety. In the absence of any root-and-branch reform of the system or a change of Government leading to GP commissioning as outlined by my hon. Friend the Member for Boston and Skegness (Mark Simmonds) in his opening speech, I should like to focus on the use of foreign doctors in out-of-hours provision and to suggest a few proposals for reform that might go some way to ensure that patients receive the high standard of care to which they are entitled under the NHS.
	My first proposal is that an assessment of English language skills should be carried out on all foreign doctors, because too many patients complain of foreign doctors' often limited knowledge of our language. We must ensure that all foreign doctors who register to work in Britain have a sufficiently good grasp of English to diagnose appropriately and to treat patients. Misunderstandings and unawareness can cost lives, particularly as many EU doctors are apparently unfamiliar with the strength of some drugs that are used in the NHS.
	As the Minister confirmed, many primary care trusts require a high level of English proficiency before a foreign doctor can register as a GP. However, the system allows for loopholes to be exploited, as not all PCTs have such high standards. The loophole enables foreign doctors who would not pass the English requirement set by some PCTs simply to apply to others that do not have such stringent rules. Even worse is the fact that a doctor who fails an English test in one PCT can withdraw his application from that PCT, leaving no trace or record in the system, before re-applying for an English test at another PCT. Thus, there is no record of a list of failures or rejections. In other words, a doctor can tout himself around the system until he finds a weakness and gets a breakthrough. Once a doctor is registered with a PCT, he or she can work as a GP anywhere in the country, regardless of the language requirements in the particular PCT area in which he or she ends up practising. The registration of foreign doctors with PCTs is an area where requirements must be standardised in order to avoid applicants exploiting such loopholes.
	As well as having these English language tests, it is crucial that the applicant's medical competence is assessed before they can register in the UK. Before being registered, doctors should be required to provide documentation to show that they have experience of working as a GP and that they have undergone specific training in general practice. All the applicant needs to do at the moment is to provide a licence to show that they are allowed to practise in their own country, regardless of whether they have actually ever worked as a general practitioner. I do not believe that that is enough, and more stringent rules are needed in this area to ensure the best possible care for patients.
	Compulsory training and induction in England before foreign doctors are allowed to work as GPs is also crucial to ensure a high level of patient care, a point made by the hon. Member for North Norfolk (Norman Lamb). That is not currently a legal requirement, and it would be interesting to hear of any plans the Government have to introduce compulsory training and induction for foreign doctors.
	The General Medical Council must consider introducing more stringent assessment before recognising medical qualifications from other EU states. Doctors from EU countries do not have to undergo the same assessment of their competence as doctors from other countries, not only those from India-that country has been mentioned-but those from countries such as Australia and the USA. It is necessary that the medical competence of doctors from EU countries should also be assessed, as medical training and types of drugs used vary across Europe. Criminal record checks should also be mandatory for all foreign doctors applying to work in our NHS and the country of origin should be obliged to supply information of previous malpractice by a doctor to the authorities in this country. At present, this is entirely voluntary, but there have been cases of doctors who have been convicted of malpractice in their own country being allowed to practise as out-of-hours GPs in our NHS.
	A national database of foreign doctors applying to work as a GP in Britain should be introduced that would hold information on language skills, levels of medical competence, criminal record checks, malpractice in the country of origin and whether the doctor has ever been rejected by, or withdrawn their application from, any PCT. Finally, as a general rule, doctors should be accountable to the laws of the country in which they practise. The Government must work with other countries to ensure that any doctor accused of malpractice, negligence or worse in this country is not allowed to escape justice being served for the crimes that they have committed.
	I hope that the Government will urgently consider the proposals for reform of the out-of-hours care system that I and many other hon. Members have proposed in the debate this evening. I call on the Government to ensure that foreign doctors are properly assessed and scrutinised before they are allowed to work as GPs in this country. We have witnessed too many cases where patients have been let down by the system and we need a complete overhaul of the provision of out-of-hours care in order properly to ensure the safety and well-being of patients. Until the Government bring in urgent and sweeping reforms to this system, people's lives will be at risk. Too many patients have had to pay with their lives already.

Mark Todd: I had not expected to speak in this debate, but the robust handling of interventions by my right hon. and learned Friend the Minister has led me to say a little more than I would otherwise have done.
	Let me first say something about the position in my constituency. When the out-of-hours service was removed from GPs and transferred to PCT commissioning, the initial results were simply horrendous. I received large numbers of complaints over poor handling of calls, lengthy delays and so on. However, I should immediately add, by way of comfort, that the PCT-not rapidly, but over time-addressed those concerns and there has been a significant improvement in the services offered in South Derbyshire. Some location changes mean that there is now an outpost in Swadlincote that serves the urban area and its environs, so a GP can reach patients in the main population hub of the area rather more rapidly than they could under the old model. There is evidence that change can take place, but I still receive complaints and we still have further to go.
	My original reason for wanting to intervene focused on the experience that I and other hon. Members had yesterday of listening to carers of those with motor neurone disease who have called out-of-hours services in their areas and the frankly very poor treatment that they have received. The most extreme example, which resulted in an apology and, I think, disciplinary action against the person involved, involved someone with NIV-non-invasive ventilation-which is the breathing system that supports someone and keeps their lungs functioning. The carer was asked to remove the mask to test that person's breathing so that the person on the other end of the phone could validate what they were saying. That was after the individual's notes had been passed to the out-of-hours service, so they should have been perfectly aware of the condition from which that person was suffering.
	Clearly, as I said in my intervention on the Minister, protocols for rare conditions-cases in which crises can readily occur out of hours-need to be strengthened so that the training level for dealing with very specific conditions is satisfactory.
	There is no way to turn the clock back and, even if there were, it would not be wise so to do. Others have already covered some of the reasons for that, but I shall expand on one. The hon. Member for Boston and Skegness (Mark Simmonds) opened for the Opposition but, despite what he said, I do not think that most GPs would want the legal and financial responsibility for commissioning services to be transferred back to them.
	My hon. Friend the Member for Dartford (Dr. Stoate) set out some of the legal issues involved. I think that they would be intimidatory, but-and I was looking for some degree of consensus on this in one of my interventions-I think that GPs could have a much stronger role in the governance of the out-of-hours service being offered.
	At the moment, there is GP representation on the professional executive committee of a PCT, but that is far too modest a function in the commissioning process. A governance board should be established to drive quality issues when a service is commissioned. That board should also be involved in the critical issue that I am now going to come to-the relationship between the various parts of the NHS in the area.
	Knowledge transfer is critical. When an out-of-hours service is offered in an area, doctors must be able to access information about patients. Earlier, I gave the example of a person with MND for whom the GP had taken the trouble to ensure that relevant information was passed on. That process should be integrated into the commissioning of the out-of-hours service, because it is critical that those who must answer a call and deal with distress have a clear idea of what the caller is suffering from and of how best to respond. That means that we need to strengthen NHS information systems. I have been a strong supporter of investing in health information systems, in spite of the difficulties that have been encountered. We must continue to get across the message that, without a robust means of transferring information within the NHS, problems are all the more likely to occur. We should always make it clear that we will never utterly eliminate risk, but we must try to ensure that the people who have to deal with crises know what they are dealing with and whom they are talking to.
	I was interested in the contribution from my hon. Friend the Member for Dartford; for a start, it is nice to hear a Member of Parliament speaking about something that he knows about. He presented interesting evidence about the different relationship between patients and out-of-hours services that arose as a result of the change in the contractual function. I think that patient behaviours are substantially influenced by that relationship.
	Essentially, the argument is that people who know their GPs will not want to ask too much of them. They know that providing out-of-hours services is difficult, so they exercise some restraint on the demands that they place on the system. However, those demands may be rather different if people believe that the services are provided by some quasi-state function with which they have no relationship whatever. It is worth thinking about how economic models apply in these circumstances, and how we might try to learn some of the lessons.
	Finally, the hon. Member for Basingstoke (Mrs. Miller), who is waiting to speak, made a very wise point about integrating out-of-hours services with the acute sector. From time to time, the acute trust in Derby has suggested establishing an out-of-hours service for my community in South Derbyshire that is adjacent to the accident and emergency function, with the aim of trying to provide common standards of treatment. It is perfectly obvious that inadequacies in out-of-hours care drive additional and often inappropriate demands on A and E services. There is therefore a shared interest in establishing common methodologies for examining demand, and common methods for dealing with patients when they arrive in distress and requiring treatment.
	As in many cases, there is in this House a huge amount of common interest and opinion on this matter. Although I do not agree with the model proposed by the Opposition, and will not be voting for their amendment, I think that, if they reflect harder on some of the points made in the debate, they will see that there is much more to build on in terms of reform than might have appeared to be the case when the hon. Member for Boston and Skegness first started to speak.

Maria Miller: Many people were shocked when they read the media stories on the issues that we are discussing. Although we cannot go into the details of those stories, it is important to recognise the concerns.
	The change in the GPs' contract in 2004 is one of the root causes of the problems that we are discussing, as nine out of 10 GPs elected to opt out of providing after-hours services. The Government simply have to accept that that was a misjudgment, and that that should not have been allowed to happen. The consequences that we are now dealing with and discussing have fallen on some of the most vulnerable people in the community. We have not spoken much about patients and the primary users of those services but, as hon. Members know, the elderly and children account for 80 per cent. of them. It is important to recognise that the problems with which we are dealing are often experienced by the people least well placed to cope with them.
	The problems with out-of-hours services, access and quality have only been compounded by cuts in other primary health care and public health services. The Minister will be aware of the problems in my part of the country caused by cuts to health visitor services-those problems have been experienced in many other constituencies, too-which puts more pressure on GPs and on out-of-hours services. As hon. Members have said, the result of difficulties accessing out-of-hours services is an increasing reliance on hospital accident and emergency departments. Imperial college London recently produced a report showing a 41 per cent. increase in short hospital stays by children under 10 between 1996 and 2006, often for chronic problems such as asthma and other respiratory problems, fever, and other things that could have been dealt with if out-of-hours services were more readily available. In some parts of the country, those services are simply not available.
	We cannot blame parents for seeking medical care for their children when they are in distress. All of us who have small children know that sometimes it is difficult to recognise whether a problem is severe or not. Access to primary medical care through the GP out-of-hours service in non-traditional office-hour times is vital, and an overhaul requires a great deal of thought. There are questions hanging over the out-of-hours service. For example, PCTs monitor response times, but do not consistently monitor the quality of care offered to patients, and the recent inquiry by the Care Quality Commission has produced some worrying findings.
	Quality of care is at the heart of what hon. Members have discussed today. The Minister said that there were three levels of quality control: the General Medical Council, PCTs and, indeed, the employer. However, as my hon. Friend the Member for Boston and Skegness (Mark Simmonds) pointed out, the GMC has said that the existing framework does not adequately safeguard patients in the system, so there is a serious flaw if people who are given the task of quality control question whether it is working. The Minister stressed the fact that legal responsibility lies with the PCT. In an intervention, however, I was surprised to hear him question whether that was enforceable. Indeed, if it was enforced, the financial consequences might fall on the taxpayer. If there is no clear responsibility and no clear consequences, I fear that we will not see any change in the quality of care offered to some of our most vulnerable constituents.
	My hon. Friend the Member for North-East Cambridgeshire (Mr. Moss) made an extremely powerful and moving contribution, and gave an excellent list of recommendations that the Minister should consider to reform the system so that we get the changes that we need. The hon. Member for Dartford (Dr. Stoate) discussed the different services provided in the NHS, and made a distinction between in-hours and out-of-hours services. Yes, I believe he is right to say that there will be different expectations of what might be delivered by those services, but my constituents and people throughout the country will expect the same quality of service, whether it is in hours or out of hours.
	A number of hon. Members mentioned overseas doctors. That is at the heart of what we are debating. The Minister talked about improvements in fitness to practise for British doctors, but did not seem to move on to how that would affect the quality of doctors coming in from overseas. The hon. Member for North Norfolk (Norman Lamb) spoke about CRB checks. He is right to say that overseas doctors coming in from any country, even within the UK, will not have had an effective CRB check.
	Before I move on to the situation in my constituency, which I would like to highlight to the Minister because I think it is an excellent model of working, I shall pick up on the issue of fragmentation within the NHS. We now have, by my calculation, five different ways of accessing NHS services. The Minister spoke about the new 111 service, a telephone service for non-acute calls. We also have NHS Direct, the 999 service, GPs in their normal office hours, and out-of-hours services. As we move forward, we should be careful about how patients understand the way in which those different elements work together. It is a maze of different ways of accessing the NHS. From talking to those who provide services in my constituency, I know that that is becoming a matter of concern.
	My constituency has a very high-quality out-of-hours service, which could be a model for other areas. The Hantsdoc service, which has been provided for the past 14 years in Basingstoke, looks after about 30,000 patients a year and is a partnership of local doctors working with the PCT in the community. They work closely with the hospital and are located in the fractures unit to reduce the unnecessary admissions that might otherwise occur. Doctors who are located centrally can see three times as many patients, and the service is open throughout the week and the weekend, when doctors' surgeries are not available. I recently visited and spoke to patients, who were extremely satisfied with the service that they had received.
	I agree with my hon. Friend the Member for Boston and Skegness when he says that there is no one answer to out-of-hours services and no one model, and that that should be driven by what is required in a the community, but I offer the work of Hantsdoc as one model that has worked for 14 years and served my constituency well.

Several hon. Members: rose -

Mr. Deputy Speaker: Order. Eighteen minutes remain before the debate is wound up, so I appeal to hon. Members to see if they can help each other in this respect.

Jacqui Lait: I will do my best to help, Mr. Deputy Speaker.
	It is interesting that we have debated the problems of out-of-hours care. That follows endless debates over the years about abuse, or the increasing use, of accident and emergency services, the problems of single-handed doctors, the provision of GP services, and the wide range of options that exist for people to access health care outside the ordinary hours of a GP practice.
	There are legitimate concerns about the out-of-hours care service. In defence of my own PCT, I should say that it is not a subject that has been raised a great deal with me, I am glad to say, but we have an extended 24-hour-a-day GP practice, a minor injuries unit, and a new accident and emergency department. However, we also have a high proportion of ageing single-handed practices, which is what has driven the breadth of provision.
	Something profound is going on with people's access to out-of-hours care. Lest I be accused of being a hard-hearted Tory, I shall quote a comment from the hon. Member for South Derbyshire (Mr. Todd), who spoke about economic modelling in the health service. There is a demand, led by patients, for widening the different forms of provision. By concentrating on out-of-hours care today, minor injuries units in another debate tomorrow, or NHS Direct in a debate two weeks from now, we are not putting together the whole provision of out-of-hours care and ensuring that the models that we offer meet the demands of a patient-led service. That is what we would dearly like to move towards, and it is the basis of my Front-Bench team's proposals on that one issue of out-of-hours care. We are trying hard to take health care out of politics, and an NHS board would be able to look across health care provision to ensure that patient-led demand was met most appropriately.
	As my hon. Friend the Member for Basingstoke (Mrs. Miller) said, there is a need for the out-of-hours service, for the terrified mother who has a child with croup, for the elderly person who suddenly has a fit, or for whatever the crisis might be. Those people cannot get to the extended GP service or to the minor injuries unit, and reaching A and E is even more difficult. However, we must bring into the debate how the ambulance service is used not just as an accident or crisis service, but almost as a social service.
	I was out with an ambulance team when they were called to put an elderly gentleman back into bed after he had fallen out, and it became palpably obvious that he was lonely. He fell out of bed deliberately to get the ambulance team around-regularly, because they all knew him. That is an abuse of the ambulance service, but it highlights how the service should be part of a seamless out-of-hours service. By focusing on those different areas separately, we do not focus on how we can meet patients' demands, and that, more than anything else, is what the NHS should deliver.

Richard Taylor: I shall try to be rapid. Out of hours comprises two thirds of the week, and most emergencies will therefore occur in those two thirds, so it is important that we have high-quality, out-of-hours care. I am green with envy at the hon. Member for Basingstoke (Mrs. Miller), who still has the old system that good GPs used long before the GP contract came in. They knew that they could not cover in-hours care as well as out-of-hours care, so they got together, formed a co-operative-my own GPs did that-and, if there were 50 of them, three could be on call for a night on only one in 17 nights.
	In the investigation by the Health Committee into out-of-hours care, it was recommended that such co-operatives have 80 GPs to cover holidays and time away, so that system could still be used. In the Committee's 2004 report on the out-of-hours service, we underlined the importance of GPs' expertise and knowledge. In a recommendation, we stated:
	"It is therefore vital that they"-
	the GPs-
	"do not become disengaged from the process of redesigning GP out-of-hours services during this critical transition phase, and their expertise and local knowledge lost."
	Existing GPs are absolutely crucial to redesigning the process.
	We know, and many hon. Members have said, that in some areas there are excellent out-of-hours services, while in others they are pretty awful. I have experience of them when they are not so good. I am purposely not naming any names, but, if such services are run by a private company, we can never discover how the tender was awarded, because of commercial confidentiality, and one has the distinct impression that the contracts are awarded simply on price. That means that the skill mix is reduced, because we have to employ fewer doctors and more emergency care practitioners. Emergency care practitioners drive themselves around, so it is not necessary to employ drivers to drive GPs around. It is obvious that when the tender is based on price, economies are made. That is why in many parts of the country it is very hard to get local GPs to take part in these rotas, so we then have foreign doctors taking part.
	I am grateful to the Minister for explaining the controls that are meant to be in place for vetting doctors who take part in out-of-hours care. It is crucial to tighten up these systems. The Health Committee hopes, before the general election is called, to have single session on vetting systems to see what can be done to improve things.
	We cannot go back to the old-style system; people who have it are extremely lucky, where it is really working. A GP who recently wrote to  The Independent bewailing the changes and the surrender of 24-hour responsibility admitted that we cannot go back because GPs are becoming deskilled. Sitting in a GP's surgery looking after patients whom one knows very well with a condition that one knows very well is entirely different from having five to 10 minutes, in difficult circumstances, trying to work out if somebody is extremely ill or not.
	Let me make-or repeat-one or two positive suggestions. Pay and conditions across the country must be as nearly similar as possible. In its submission for this debate, the BMA says that in some areas funding for out-of-hours care is only £3 per head, while in others it is £16. Are the best out-of-hours services those that are the best funded? We do not know, and a survey of that nature would be very helpful.
	An absolutely vital move, for which I have been pushing since the tragedy in my constituency in 2007, is the 111 number. I think that the hon. Member for Basingstoke slightly misunderstood the importance of the 111 number, which is intended to bring together every other service apart from the emergency services. If someone knows that they need to call 999, okay, it is a matter of life and death, and that is what they do. If they live in my area, where there is no A and E department that they can walk into, they have seven or eight different alternatives. The whole point of the 111 number is that it is tied to the area that a person lives in, and with one call it tells them whether to ring NHS Direct, whether to go to the out-of-hours centre or whether to go to the minor injuries unit.
	That system is absolutely ideal. If it is joined together with a really efficient triage system such as NHS pathways, which Ministers know all about, and which is being rolled out in some places, it could make a huge difference, particularly to people who do not have a local A and E department, and relieve the stress on A and E departments by ensuring that only the right people go there. Knowledge transfer, which has been mentioned, is crucial. Why cannot the triage people, as soon as somebody phones up, flash up their summary care record in front of them so that they know exactly what is going on?
	Finally, I should like to clarify what the BMA said. For once, the BMA, which we in this place tend to think of as the doctor's union that thinks only of doctors, got it exactly right. I will read the very last bit of its submission:
	"The BMA believes that standards of out-of-hours care could be improved if PCOs"-
	primary care organisations-
	"involved local GPs in...commissioning".
	It states not that GPs should do the commissioning, but that they should be involved in it and advise the primary care organisation. It goes on to say that that involvement should happen so that
	"high-quality, timely and cost-effective services can be developed that are sensitive to local circumstances."
	I cannot understand any political party disagreeing with that.

Nadine Dorries: The Minister was right to identify fatigue as a reason for the out-of-hours service as we know it having been developed. Many GPs were very fatigued and it was impossible for them to continue under the system that was in place. However, the current out-of-hours system was then imposed on them, so my constituents went from having GPs who had no room for manoeuvre and were fatigued to having an out-of-hours service in which GPs are working abroad in Poland, Germany and other countries and flying over here on a Friday night. That service is therefore being delivered by fatigued out-of-hours doctors. At the great capital expense of changing one system to another, there is absolutely no difference in the level of care for many constituents-they are being provided with care by fatigued GPs. In many cases the care is much worse because of the language barrier and various other reasons that we have heard today.
	There are attempts to minimise the importance of the rise in complaints, but I do not believe that we can do so. As we know, the people who complain about the out-of-hours care service are those who are able and motivated to do so. We do not find the poor complaining, because they are grateful to get any help they can. The vulnerable, the needy and the elderly do not complain, because it is not in their make-up to complain about something that they see they are getting for free, such as access to the NHS. Yet the poor, the elderly and the vulnerable are the people who will use the service the most. There are also parents with children, and they have other things to see to. We can therefore probably accept that the number of complaints should be ramped up to take into account those who do not complain.
	We have a system that is no better for patients than the one that the Government were trying to replace. Amazingly, it is evaluated by response times, not by the quality of care that is delivered to patients. What is the point in thinking that the service is good if a GP is there within 20 minutes, if the care that he delivers when he arrives is of poor quality? That is simply not good enough. Should not the primary evaluation be the care that is delivered when the doctor arrives at a patient's house?
	The hon. Member for Dartford (Dr. Stoate) said-I am sure he will correct me if I am wrong-that different GPs provide different care throughout the country, which is true. They are providing different care in communities that have varying needs, with different health care provision commissioned in different ways by varying PCTs. I imagine that it is almost impossible for a doctor to come from overseas, be in a different area each time he arrives here and know what he is supposed to deliver and how he is supposed to access the ongoing care that his patients need. Does it not therefore make sense to have local budgets, provided to GPs so that they can commission their own care in the way they need to?
	I understand the concerns that the hon. Gentleman raised from his very experienced position. However, there are contracts and then there are contracts. There are ways for local GP practices to commission care so as to protect themselves, so that they are not ultimately responsible for the care delivered. That problem of responsibility needs to be circumnavigated. It should not be a wall that we come up against and say, "You know what? We can't do it, because it means the GP is ultimately going to be responsible."
	My hon. Friend the Member for Basingstoke (Mrs. Miller) talked about the services in her area. I have similar services in Bedford. Our accident and emergency facility in Bedford hospital makes provision for patients to receive the equivalent of out-of-hours care for a certain amount of time. That is a good way of triaging out the patients who can be seen by nurses and out-of-hours doctors because otherwise they impose a cost on the PCT. It is an excellent model, but it cannot be delivered in rural areas or in every community throughout the country.
	I believe that, although many GPs do not want to return to a system whereby they are exhausted and expected to work all week and then all weekend, they would welcome being trusted again with a real budget to commission the care that they need. They know their patients, the type of care that they need and how best to deliver a service locally. In many areas, GP practices are grouping together to provide their own out-of-hours service because they want to deliver a service locally that they know their communities need and appreciate.
	If local people were unhappy with the service, would they not go straight to their GPs to complain? Is it not easier to complain to a GP if people are seeing him anyway, and they know that he is responsible for commissioning the out-of-hours care? Are not they likely to say, "I called out the doctor last Saturday, and I wasn't happy with what happened"? It is a much easier way for GPs to get to know what is delivered on the ground. They can then modify and adjust the service that they provide to suit their community.
	Local budgets, practice-based commissioning, and GPs having a real responsibility for what they provide and how they provide it makes perfect sense for patient requirements, local needs and patients' ability to adapt that service if and when they want.

Michael Penning: We have had an eminently sensible debate this afternoon. Hon. Members of all parties care about the quality of care that our constituents get. Sometimes we disagree slightly-and sometimes more than slightly-about how it is delivered, but we all care passionately.
	Contributions have been measured and understandably passionate. I pay tribute to my hon. Friend the Member for North-East Cambridgeshire (Mr. Moss), who, like us all, would have loved to raise constituency concerns and effects on his constituency. His speech was extremely measured, and he will be a great loss to the House when he retires at the next election.
	I am conscious that other hon. Members are retiring at the next election, and I apologise if I do not have time to respond to all who spoke.
	The key to many of the contributions was safety-for our constituents and the patients who look to the NHS to give them the care that they deserve and that we would all expect. The problem with the existing contract is that many patients do not feel they are given the care that they deserve, whether they live in rural or urban areas. We have heard much about the different sorts of care that we are offered in rural as well as urban areas. My seat is both very rural and very urban, so I well understand the problems.
	The hon. Member for South Derbyshire (Mr. Todd), who eventually decided to take part in the debate-I understand why, and I repeat that it was a sensible debate- made some important points. The first was about knowledge and records. Do people who are called out out of hours know the patients' concerns? We talked about multiple sclerosis, motor neurone disease and other conditions. It is imperative that that information is available when possible. That is why the link to the GP is so important.
	As the hon. Member for Dartford (Dr. Stoate) knows, I often bow to his medical knowledge. He is a GP, and I serve on the Health Committee with him. I think he said that GPs grabbed the contract with both hands only to remove the risk and perhaps some of the tiredness from it. That is not quite right. GPs were offered a contract by the Government in 2004-frankly, if they had not bitten their arm off, they would have been silly, because the financial benefits were huge. The contract was fantastic for GPs who had been working through the nights and at weekends. All they had to do was give up £6,000 a year-£120 a week. Nine out of 10 did that. I do not think anyone would take on such a work load for such a small amount of money. It is difficult for a hard-working MP who is also a GP to say that this is about tiredness. Surely he is exhausted when he leaves the House late at night or in the early hours of the morning and goes on to be a GP in the morning. The amount of work he does in his constituency must make him a very tired GP, which is worrying.
	My hon. Friend the Member for Mid-Bedfordshire (Nadine Dorries), like many colleagues, touched on continuity and safety for patients and what they expect from the NHS. The debate has been very much about-I hope-patient-led services. The key is not what the NHS, GPs or NHS Direct want, but what is right and proper for patients. Quite rightly, we have talked extensively about GPs and GPs out of hours, but that is only part of what we should rightly talk about today.
	My hon. Friend the Member for Beckenham (Mrs. Lait) said that we should have a debate not about NHS Direct, out-of-hours care and A and E, but about what a joined-up package would be. One problem with the existing PCT packages is that they are not integrated. There are myriad contacts out there-there are polyclinics and Darzi clinics, care clinics, walk-in units, GP surgeries in railway stations, NHS Direct and NHS Choices.
	There are so many different things that it is not surprising that our constituents are confused, which is why I was over the moon when the Government adopted our policy of going to a second number, 111. The number is fine, but do the Government understand what it should involve? I was slightly concerned when my good friend, the hon. Member for Wyre Forest (Dr. Taylor), said that people could be given another number to call after they called 111. That is not the idea. The idea is that people should be triaged through the phone system. Once they have had the courage or fear, or felt the need, to pick up the phone, they should be able to triage right the way through. Once they have dialled 111, they should be able to go all the way through so they can find out which pharmacy is open that night, whether they need to go to A and E, or whether an ambulance should be called to them immediately.
	I understand that none of the three pilots includes access through the web portal, which is wrong. We need to have a joined-up situation. We should offer a single 111 service, but it should be replicated on the web. At the moment, that is not included in the pilots. Will the Minister look at that, because it is very important?
	Finally, if we want to talk about out-of-hours services, we must look at the emergency care single pathway. As I said, the 111 number is eminently sensible, and I am pleased the Government are using it, but we must look at what service is needed by our constituents when they phone up. Should we look at pharmacies, walk-in centres and social care? Should it be possible to tell people whether they need to make a GP appointment the next day, whether a paramedic needs to be sent straight away and whether that should be a single-responder?
	The Minister would be surprised if I did not mention out-of-hours dentistry, which is in crisis-dentistry is in crisis during the day and at night. If the Minister went to A and E units at night and talked to patients, he would find a huge number who are there simply because they cannot get a dentist during the day. We know that in excess of 1 million patients cannot access NHS dentistry, but when people are in pain and turn up at A and E, we need to ensure that the skill base is available for them.
	My hon. Friend the Member for Basingstoke (Mrs. Miller) talk mentioned walk-in centres integrating with A and E. I have seen that in action and it absolutely works around the country and releases a lot of the pressure from existing A and E units. I am sure all hon. Members visit their A and E units-I am lucky enough to go and visit very many. Many patients could have been seen at a minor injuries unit, but they go to the A and E because they feel safe. Many in A and E wanted to get a GP appointment but could not, and many are sent to A and E after a long call to NHS Direct, when they could have been triaged in a much better way.
	Working as an integrated service is crucial if we are to have the out-of-hours and urgent care that we need. The Government disagree with our policies-that is their prerogative-but they should call an election and let the public decide.

Ann Keen: I too wish to say how well this debate has gone. There have been improvements in out-of-hours services in the last 12 years. They are good, but they are not great. They have let some people down and we need to improve them further. That is why we have asked Professor Steve Field, the chairman of the Royal College of General Practitioners, and Dr. David Colin-Thomé, the director of primary care services in England, to review the out-of-hours service. The report by the Quality Care Commission will also be presented shortly. We have more work to do on out-of-hours services and we intend to improve them. We need to ensure that PCTs and employers do the checks that are needed.
	The hon. Member for North Norfolk (Norman Lamb) said that he wanted to see checks on language and professional competence, and that those should be carried out by the GMC. He claimed that that would require changes to the EU directive. We cannot wait that long. The issues need to be addressed now. PCTs have a legal responsibility to ensure competence in the English language and the practice of medicine. Employers should also have that responsibility, and we need to ensure that that is done. Reform of the EU directive is not necessary to achieve that.
	My right hon. Friend the Member for Rother Valley (Mr. Barron) chairs the Health Committee and is well known for his detailed opinions on health. I shall address his points throughout my speech. As my hon. Friend the Member for Dartford (Dr. Stoate) said, with obvious authority, responsibility for out-of-hours services lies with the PCT. The hon. Member for Boston and Skegness (Mark Simmonds) says that he would transfer responsibility for commissioning of out-of-hours services to GPs. They would therefore be liable in law for any failures by locums they employ, or any negligence or failures by an employed GP. It is no wonder that the BMA is concerned about Conservative policy, which would lay a similar liability on GPs to that which they had before 2004.
	My hon. Friend the Member for South Derbyshire (Mr. Todd) spoke movingly about the care of long-term conditions. Such conditions require a different out-of-hours service. In many instances, they require a rapid response team, and many such teams are in place. They are multi-disciplinary, including paramedics and specialist nurses. The hon. Members for Basingstoke (Mrs. Miller) and for Beckenham (Mrs. Lait) also spoke of the need for health care teams with different skills, including physiotherapists, paramedics and nurses.

Martin Salter: My hon. Friend mentions nursing. I am interested in the development of policy in that area. Does she intend to follow the Leader of the Opposition and meet the Nurses for Reform campaign group which advocates the wholesale privatisation of the NHS, including out-of-hours care?

Ann Keen: My hon. Friend raises an important point. I wonder whether Opposition Front Benchers have met that group- [ Interruption. ] Have you met them?  [ Interruption. ]

Mr. Deputy Speaker: Order. I have not met anyone.

Ann Keen: From what I have read of that group, my hon. Friend's remarks are very worrying.
	The hon. Member for Wyre Forest (Dr. Taylor) spoke of the 111 system, which will be excellent. I am pleased to see that the pilots may be ready as early as May or June. He made a point about the BMA involving GPs in commissioning, but I would go further and look for more nursing staff to be involved in the commissioning of services.
	As usual, the comments by the hon. Member for Mid-Bedfordshire (Nadine Dorries) did not disappoint me.
	I thank all hon. Members who contributed to this debate and I know that they would want to thank NHS staff. Illness, accidents and ailments pay no attention to the time of day, so we must do all that we can to ensure that patients get the right treatment, at the right time and in the right place, and we must have a system of out-of-hours and urgent care that is achieving that goal. People can now access the NHS in more ways than ever before: through one of the 112 new GP surgeries in the areas with the fewest doctors and the greatest need, and through the new GP-led health centres, of which there is one in every primary care trust, open from 8 am until 8 pm, seven days a week, 365 days a year-there is an excellent one up and running in the heart of Hounslow, and the treatment for my constituents is second to none. People can also access the NHS through local pharmacies, some of which are now open seven days a week and into the night; through minor injuries units and urgent care centres, many of which are nurse-led; and through NHS Direct, either over the phone or online. With so many options to choose from, it is important to give patients and local communities the information to get the help that they need.
	The hon. Members for North-East Cambridgeshire (Mr. Moss) and for North Norfolk talked about the patient, Mr. David Gray. Many have expressed their concern and sympathy about that case, and I would like to align myself with that and with the dignity shown by the hon. Member for North-East Cambridgeshire.
	We owe the NHS a great tribute, but we also owe our patients and constituents right and safe care, whether in respect of long-term conditions or urgent dental treatment-many of our dental practices also operate out-of-hours services. Many dentists should be commended for their work rather than constantly criticised for a lack of commitment. They want to contribute to primary care in every way possible by being at the heart of our communities, and many want to, and will, work in the walk-in centres of the future. We are encouraged by the people who work in the NHS and, in particular, by how people want to work in communities. It has been difficult to correct the out-of-hours service, which before 2004 was not effective, but equally the schemes now in place will need the review to be led by Professor Stephen Field. When he reports back, which should be soon, I believe that we will act on it.
	We have said that we will address the areas of change in relation to the European rulings, and that we will look at commissioning, because that is key to providing the correct services for all patients. Any GP working for out-of-hours providers is subject to the same checks as all other doctors working in general practice in England. Employers have a duty to ensure that all the doctors whom they employ are suitable for the provision of the services that they are employed to provide, and all doctors, including locums, must be on a PCT's performers list before they can provide primary medical services.
	Concerns about individual doctors can be investigated by the GMC, which can, when justified, remove a doctor from the medical register on fitness-to-practise grounds. All our services must be safe and of a high quality. They will be checked by the Care Quality Commission or the other regulators that will be needed. When I look at the extension of patient services since the resources that have been put into the health service, I feel confident that we will continue to improve our practices in every way possible for our constituents, and that is thanks to NHS staff and the commitment that they show.

Question put (Standing Order No. 31(2)), That the original words stand part of the Question.
	 The House divided: Ayes 176, Noes 267.

Question accordingly negatived.
	 Question put forthwith (Standing Order No. 31(2)), That the proposed words be there added.
	 Question agreed to.
	 Main Question, as amended,  put and  agreed to.
	 Resolved,
	That this House supports family doctors as the bedrock of healthcare services in the NHS; welcomes the improvements in out-of-hours and urgent care services over the last 12 years; notes that the Carson report in 2000 identified the need for the reform of out-of-hours care which was carried out in 2004; further notes that by the start of 2004 only five per cent. of patients saw their own GP out of hours; acknowledges that GP organisations say that they do not want a return to the system which existed in 1997; understands the continuing need to improve the quality of out-of-hours care; notes that the Government commissioned the first national out-of-hours benchmark to help primary care trusts and providers improve the quality and productivity of out-of-hours services and to reduce local variation; recognises the improvement in healthcare after the introduction of the GP contract in 2004, which has significantly extended weekend and evening opening of surgeries for routine, bookable appointments; recognises that over 77 per cent. of GP practices now offer extended opening hours and that every primary care trust is developing a new GP-led health centre, open from 8 am until 8 pm, seven days a week, 365 days a year; and welcomes plans for people who need urgent care to be able to dial 111 for advice 24 hours a day, seven days a week.

Business without Debate

DELEGATED LEGISLATION

Motion made, and Question put forthwith (Standing Order No. 118(6)),

Road Traffic

That the draft Motor Vehicles (International Circulation) (Amendment) Order 2010,which was laid before this House on 5 January, be approved. - (Helen Jones .)
	 Question agreed to.
	 Motion made, and Question put forthwith (Standing Order No. 118(6)),

Planning

That the draft Overhead Lines (Exempt Installations) Order 2010, which was laid before this House on 6 January, be approved. - (Helen Jones .)
	 Question agreed to.

EUROPEAN UNION DOCUMENTS

Motion made, and Question put forthwith (Standing Order no. 119(11)),

EU Enlargement Strategy

That this House takes note of European Union Document No. 14513/09, Commission Communication on Enlargement Strategy and Main Challenges 2009-10; and supports the Government's policy that Turkey, Croatia, Iceland and all the countries of the Western Balkans should be able to join the EU when they meet the criteria.- ( Helen Jones .)
	 The  Deputy  Speaker's opinion as to the decision of the Question being challenged, the Division was deferred until Wednesday 3 February (Standing Order No. 41A).

BUSINESS OF THE HOUSE

Motion made,
	That, at the sitting on Thursday 28 January, notwithstanding Standing Order No. 20 (Time for taking private business) the Private Business set down by the Chairman of Ways and Means may be entered upon at any hour, and may then be proceeded with, though opposed, for three hours, after which the Speaker shall interrupt the business. - (Helen Jones .)

Hon. Members: Object.

SECTION 5 OF THE EUROPEAN COMMUNITIES (AMENDMENT) ACT 1993

Motion made,
	That, for the purposes of its approval under section 5 of the European Communities (Amendment) Act 1993, the Government's assessment as set out in the Pre-Budget Report 2009 shall be treated as if it were an instrument subject to the provisions of Standing Order No. 118 (Delegated Legislation Committees). - (Helen Jones .)

Hon. Members: Object.

Barry Gardiner: On a point of order, Mr. Deputy Speaker. Mr. Speaker has given his full support to the work of the Youth Parliament and I seek your ruling, Mr. Deputy Speaker, as to whether it is in order for a public body to seek to intimidate its members in any way.
	Recently, my hon. Friend the Member for Brent, South (Ms Butler) invited young people who were members of her Facebook group to visit her in Parliament. Many of those young people were also members of the Brent Youth Parliament. Shortly thereafter, members of the Youth Parliament received a letter from Brent council's senior lawyer. The letter stressed that Brent Youth Parliament is supported by the London borough of Brent and it counselled them as follows: "You will obviously need to give careful consideration as to whether you wish to align yourself with a particular person or group and what impact this may have on others' perception of you as a Brent Youth Parliament member. If you do decide to participate in local politics, you will need to give consideration as to which person or group you are willing to be connected with and any implications of this."
	Many of these young people have been frightened by the letter and regard it as a warning shot. They have previously believed that Brent council was encouraging young people to become politically active, but they now consider that it encourages them only if they are sympathetic to the Liberal Democrats. What action can this House take to ensure that these young people are not bullied in this way by a local authority?

Mr. Deputy Speaker: May I say to the hon. Gentleman that that is not a point of order for the Chair? I think that it is a matter that he might have dealt with better by writing to Mr. Speaker, whose interest in the matter he has cited. This is now taking time out of the Adjournment debate. He has put that on the record and he may wish to take it further in the manner that I have suggested.

PRIMARY AND SECONDARY EDUCATION (DEVON)

Motion made, and Question proposed, That this House do now adjourn. -(Helen Jones.)

Richard Younger-Ross: Devon's education authority is one of the worst funded in the country; its standing is 148th out of 151. Indeed, only Leicestershire, South Gloucestershire and Hertfordshire have less per pupil funding than Devon. This is not a new problem; it dates back to the funding formulas set up in the 1980s.
	I wish to cite what a local head teacher has said and to give voice to the number of people from across Devon who are concerned about the issue. This is about their concern and anger, so I wish to put their words on the record.
	Chris Bray, who was head of the Abbotskerswell school, said that when he was head at Abbotskerswell, the Conservative Government brought in a funding system that gave Devon schools less than virtually every other authority in England-£96 per pupil in 1994, rising to £145 in 1995-and that it has continued to get worse. That is the gap in funding, on average, compared with the rest of the country.
	Recognition has to be given that the Labour Government have put more money into education, but the system of grant per pupil is now worse because it is fixed on a cost-plus basis rather being based on the criteria of what drives the costs in the school. Changes in make up and in deprivation in an area are no longer a matter for consideration because the funding is fixed at a point in time five years ago, when the current criteria were set up, using a faulty system, as I have already explained, from 20 years before that.
	The top funded council in the country is currently the City of London, where pupils get a grant in the order of £7,603. The 10 best funded areas per pupil receive £6,252. The national average funding for each school pupil is £4,217. In Devon, it is only £3,842. I am at a loss to understand how that grant of £375 less than the national average can be justified. I looked at the individual schools, and we worked out a little list from the rolls of the schools in my constituency. Let me pick a couple of examples.
	Abbotskerswell primary, a small school, has a funding deficit of £29,250. Let me look at some of the larger schools. Hazeldown, which is also a primary school, has a deficit of £145,000. The situation for the secondary schools is even worse. Dawlish community college is losing £324,000, Teignmouth community college £394,000, South Dartmoor community college £615,000, Teign school £519,000 and Newton Abbot college £362,000. Those are all substantive sums of money-enough, in most cases, to employ 10 teachers. That is one of the main complaints of pupils, parents, governors and teachers. Given more resources, they could do more with what they have.
	It can be argued that in Devon, of course, we do very well. We have high standards and educational attainment is in the top third in the country. That is true, but it is no good just considering the 50 per cent. We must consider the rest of the pupils and what happens to them. It is the pupils who have difficulties, who have been statemented or who come from areas of social deprivation who are losing out. I would consider it a fundamental aim of any education system to create equal opportunity, and that is being lost in Devon because it is not getting a fair slice of the cake. The original formula fails to take into account the rural deprivation in Devon and the costs associated with travel for pupils and staff.

Hugo Swire: Devon county council is responsible for 8,000 miles of road, more than any other authority in the country. The school transport bill is now in excess of £22 million a year. Does the hon. Gentleman not agree that any fair funding formula for education in Devon must take into account rural sparsity and the high cost of transporting children to school?

Richard Younger-Ross: The hon. Gentleman makes a very good point: of course any such formula must take account of that. Indeed, the director formerly responsible for the county's highways and environment was wont to say that there were more roads in Devon when Plymouth and Torbay were part of the greater council than there were in the whole of Belgium. That gives some idea of the scale of the problem. Plymouth and Torbay are no longer part of that road network, but it is still vast and people still have large distances to travel.
	I know that the hon. Member for East Devon (Mr. Swire) has a large constituency, but mine covers 660 square miles. It takes me two hours to get from one side to the other. People live in small pockets, and they have to travel long distances to get to the main hubs and to their schools. He has made a very good point.
	The great distances that people must travel affect pupils' attendance at after-school clubs, and also parental choice, as the options are reduced. The county has a real problem when people who wish to assert their parental choice are denied it because the travel budget has to be made to work. In one year, the Government allocated some £5 million in grant for travel-I am not sure of the exact figure-yet the real cost was three times that. As a result, the county had to take money from elsewhere to be able to fund its transport needs.
	A slight reduction in pupil numbers results in a grant cut, yet core staff must still meet curriculum requirements. That is a particular problem for the small schools that are to be found in rural areas. A campaign group, the F40 group, is campaigning for under-funded education authorities. When the Minister for Schools and Learners addressed its conference on 3 November, he said:
	"We want to work with F40 to make sure that that fairness I've talked about is built into dedicated schools grant funding from design stage to distribution. It's one of the reasons why we ordered the funding review last year-so that we can develop a single, transparent formula for the distribution of DSG that's in line with relative need."
	We welcome what the Minister said, but in answer to the question of whether the Government were still committed to small schools, he said:
	"Yes, we are. We know that they're an important part of the rural landscape and an important factor in keeping rural communities alive. And I am pleased to say that the presumption against closing rural schools, which we introduced in 1998, has reduced the number of closures from around 30 a year to an average of around 9 or 10 a year now."
	In my view, nine or 10 small rural schools closing every year is still too many. They are the heart of their communities, and they have an important role to play in keeping them together.
	Devon county council has launched a campaign for fair funding. In a press release dated 16 October, the chairman of the Devon Association of Primary Headteachers-Gary Chown, the head teacher at Tiverton's Wilcombe primary school-said:
	"We are not asking for special treatment. What we want is for Devon's schoolchildren to be treated fairly."
	He went on to say that
	"staff costs account for around 80 per cent. of a school's running costs. It costs roughly the same to employ a teacher anywhere in the country because of the national pay scales. Books and equipment cost the same. So do most of the running costs of a school. And in Devon many remote schools have to pay more for such services as Broadband because of their distance from the main hub."
	The chairman of the Devon Association of Governors, Don Paterson, is also chairman of the governors of Newton Abbott college in my constituency. He said:
	"We do not dispute for a moment that the Government has put more money since 1997, but percentage increases in school funding merely means that the gap is widening all the time between Devon schools and their better-funded colleagues in other parts of the country."
	Josh Wright, the spokesman for the teachers' unions, teaches at Honiton's community college, and the Minister might expect him to be on the Government's side.
	He said:
	"My colleagues are at the chalk face, and we know what a difference we could make to our students' education if we were fairly funded. An extra teaching assistant, another field trip or an additional piece of kit in the classroom could really help a student to get the best from their education. Children only get one chance at education and it is really unfair that Devon children are penalised because of the postcode lottery of school funding."
	Other quotes have been sent to me since I secured the debate, and I shall read out a couple more before I conclude and allow the Minister to respond. I could actually have read out enough to fill 45 minutes-I know that I cannot, Mr. Deputy Speaker, and I do not intend to do so. Such is people's anger that when I sent out a request for them to write to me, my inbox was flooded with e-mails from constituents.
	Nick D'Agorne, head of North Tawton primary school, said:
	"As regards unfair funding, all I need to do is share with you our class sizes!...I have had to refuse three families last term as we cannot fit the children into the large classes. So why not employ another teacher? We are unable to employ another teacher as we would have to make TAs redundant and not give support for the teachers in the mornings."
	Jo Frith, a governor at the Littletown primary school in Honiton, said:
	"At current levels of DSG settlement, we are predicting that we will have to have mixed-year group classes in key stage 2, with more than 30 per class in order just to keep ourselves in the black".
	Is it not a disgrace that after years of promises on "Education, education, education", schools have been forced to adopt class sizes of over 30? I thought that we had a commitment to get rid of that.
	I shall end with a final quote, from David Fitzsimmons, the principal of Holsworthy community college:
	"If we truly want to achieve a world class education system, we have to tackle the underachievement and the needs of the 50 per cent. or so of children and young people who are not achieving the national benchmark in GCSE results tables."
	In short, it is a disgrace that for the past 20 years, Devon schools have not received what they should have received to enable them to educate the young people-the children, the school pupils-in Devon. The fact that they achieve such high results, with such meagre resources, is a testament to their dedication, which is what I would expect from their profession. The Government are reviewing the system, and I welcome their recognition that it is not quite how it should be. In doing so, I hope that the Minister will be positive and say, "It is not necessarily broke, but it ain't working quite as it ought to." Is it not time that local authorities such as Devon had their fair share of the cake?

Diana Johnson: I congratulate the hon. Member for Teignbridge (Richard Younger-Ross) on securing this debate.
	The funding of education is a topic that my Department takes seriously, and we want to make sure that we get the right amount of funding for our schools, because that allows our schools to give the right amount of support to their students, as well as enabling them to pay for the appropriate numbers of staff to meet the needs of their pupils and manage the upkeep of their school. Funding in Devon has been the subject of previous meetings with other hon. Members and has led to a petition on the No. 10. website. The campaign has been very effective in raising the issue.
	Before I address the concerns that the hon. Gentleman raised, it is appropriate for me to point out the unprecedented funding that the Department has given to address decades of underinvestment in our schools. I am pleased that he recognised and paid tribute to that. There has been a national revenue funding increase of £2,410 per pupil between 1997 and 2010. That has seen the previous average revenue funding of £1,808 that was spent on each pupil back in 1997 increased to record levels of investment of £4,218 in 2010.
	We want to ensure that that investment is built upon steadily, so that each school gets the right amount of funding to support its students and staff. That was the chief aim when we set up the dedicated schools grant in 2006. The amount was calculated by the SpendPlus model, which took the per-pupil spend by each local authority in 2005-06 and applied an increase to it. This model of funding was used in 2006-07 and 2007-08 and, following extensive consultation with a wide range of stakeholders, it was decided that the formula would also be used for 2008 to 2011. Using the formula has created stable and predictable funding levels for all local authorities. It is worth noting that in the pre-Budget report in December 2009, there was a significant commitment to increase spending on schools in real terms between 2011 and 2013.
	That brings me on to funding for Devon. I understand that the funding that schools in Devon receive has been an issue for some time, and that there has been a debate about it for several years. I appreciate the concerns of the hon. Members for Teignbridge and for East Devon (Mr. Swire). It is our intention to provide all schools with the appropriate funding for their area. We want to ensure that all children get an excellent education, and children from disadvantaged backgrounds need extra support from their school to make that a reality.
	Such support requires funding, and the appropriate school funding reflects the needs of each area. Devon has fewer pupils from disadvantaged backgrounds than other local authorities, which is a contributing factor to the amount that it receives. Only 8.5 per cent. of Devon's funding settlement in 2009-10 was for disadvantaged pupils. That compares with the national average of 12 per cent.
	Let me pick up on the comment from the hon. Member for East Devon about school transport. School transport is funded not from the dedicated schools grant, but from the general local government fund. Part of the funding in the dedicated schools grant is specifically for sparsely populated areas, because we all recognise that the cost of running a small rural school is much higher than the cost of running an inner-city school. Consequently, Devon will receive this year £9.38 million to cover the cost of its sparsely populated areas.

Hugo Swire: I am aware of the dedicated schools grant of £9.38 million to cover all aspects of sparsity, but the transport bill is more than £22 million a year.

Diana Johnson: I heard the hon. Gentleman's comments on that, but as we are talking about the funding that goes into schools in Devon, I thought it was worth making it clear that that part of the expenditure on school transport is separate from the school funding directly to schools, which is the main thrust of the debate.
	Staffing, managing staff and how much teachers are paid were among the issues raised. Schools are free to make choices between priorities, but they have a responsibility to make tough decisions and to operate within their funding allocation. It should be a matter of course for each school to review how it deploys its resources, including staffing.
	On rural deprivation, I appreciate that young people in rural areas may find it more difficult sometimes to access services and opportunities, but we still have high expectations of services and activities being made available in all areas, not just in towns and cities. The White Paper "Your child, your school, our future" published last year set out our vision for a 21st century schools system, in which every child can get access to the support and activities that they need to succeed.

Richard Younger-Ross: Does the Minister accept that it is very difficult to measure rural deprivation? One reason why Devon loses out on funding is that the measures that are used to look for rural deprivation are a very blunt instrument. We need far more refined tools to work out the real poverty and deprivation in rural areas.

Diana Johnson: I am certainly happy to come on to deprivation as one issue that might be put out to consultation when we consider the funding formula that we use in future.
	To return to our expectations, we recognise that schools will not be able to deliver everything on their own, and that is why we are encouraging schools to work in partnership with other schools and services, especially in rural areas. Our expectation is that they will work together to deliver for all their pupils, using pooled and combined budgets where appropriate to maximise efficiency and get the most from their money. On raising Devon's funding to the national average, I should say that funding should reflect the needs of each local authority, so some authorities will receive an education settlement that is lower than others. I appreciate that the current funding methodology does not necessarily wholly reflect the costs and pressures that local authorities face, but the hon. Gentleman will understand that the SpendPlus model has brought a great degree of stability and predictability to the system. Indeed, the guaranteed units of funding for 2010-11 have been available since 2007, enabling schools and local authorities to plan effectively, but we recognise the need to move to a needs-based formula, and that is why we are undertaking the dedicated schools grant review. With 152 local authorities to fund, with many costs and pressures to consider and with a finite amount of funding to distribute, it is not right for everyone to receive the national average. It is right that we invest our resources where they are most needed.
	Let me be clear: there will be no change to the Government's funding settlement for education in 2010-11. In 2007, we consulted on the school funding arrangements for 2008 to 2011, which we published prior to our announcement for the settlement in November 2007. The Department has been very open, highlighting since then that the current spending period will not be as generous as in previous years. It would not be right to reopen the funding settlement now. Doing so would create additional pressure on an already tight settlement and take away from the excellent work that local authorities and schools have done, through planning, on how to use that money effectively. Devon county council, like all other local authorities, has had an indicative budget for three years since 2007 in order to enable it to plan and use the money wisely.
	I agree with the hon. Gentleman that the funding of schools should be fair and even throughout the country, and that is why we are carrying out a review of the dedicated schools grant. We want to be able to develop a formula for use from 2011-12 and onwards that properly reflects the needs of every local authority. We have to take into account factors such as deprivation, the number of high-cost pupils, sparsity and the higher cost of employment. At this point, I cannot commit to the outcome of the review or promise what the formula will be, but the hon. Gentleman should know that we are working very hard towards a fairer funding system, and we expect to publish the consultation soon.
	In conclusion, I again commend the hon. Gentleman for his proactive role in bringing this topic to the Floor of the House. I hope that he, along with other hon. Members who represent that part of the country, will feel able to participate in the consultation on the dedicated schools grant, once it is published in the weeks ahead.
	 Question put and agreed to.
	 House adjourned.